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THE  ATLAS  OF 

HEART  DISEASE 

AND  STROKE 


DR  JUDITH  MACKAY  AND  DR  GEORGE  A.  MENSAH 


Published  by  the  WORLD  HEALTH  ORGANIZATION 

in  collaboration  with  the  CENTERS  FOR  DISEASE 

CONTROL  AND  PREVENTION 


The  Atlas  of 

Heart  Disease 

and  Stroke 


World  Health  Organization 
Geneva 


In  the  same  series: 


The  Tobacco  Atlas 


Inheriting  the  World: 
The  Atlas  of  Children's  Health  and  the  Environment 


The  Atlas  of 

Heart  Disease 

and  Stroke 

Dr  Judith  Mackay  and  Dr  George  A.  Mensah 


Wl 


ith 


Dr  Shanthi  Mendis  and  Dr  Kurt  Greenlund 


World  Health  Organization 

o 

Geneva 


The  Atlas  of  Heart  Disease  and  Stroke  ©  World  Health  Organization  2004 
All  rights  reserved 

O 

First  published  2004 
1    3   5   7  9   10  8  6  4  2 

WHO  Library  Cataloguing-in-Publication  Data 

Mackav,  Judith. 
The  atlas  of  heart  disease  and  stroke  /  Judith  Mackay  and  George  Mensah; 

with  Shanthi  Mendis  and  Kurt  Greenlund. 

1  .Heart  diseases  -  epidemiology   2 . Cerebrovascular  accident  —  epidemiology 

3. Risk  factors  4. Atlases   I. Mensah,  George.    II. Mendis,  Shanthi. 

III. Greenlund,  Kurt.   IV.Title. 

ISBN  92  4  1562768 
(NLM  Classification:  WG  210) 

Produced  for  the  World  Health  Organization  by 

Myriad  Editions  Limited 

6-7  Old  Steine,  Brighton  BN1  1EJ,  UK 

http://www.MyriadEditions.com 

Coordinated  for  Myriad  Editions  by  Candida  Lacey 

Edited  by  Hayley  Ann 

Design  and  graphics  by  Corinne  Pearlman 

Maps  created  by  Isabelle  Lewis 


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o  o7 

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Contents 


Foreword 

by  Dr  LEE  Jong- Wook,  Director-General,  World  Health  Organization  9 

Preface  1 1 

Acknowledgements  12 

About  the  authors  1 5 


CARDIOVASCULAR  DISEASE  16 

Types  of  cardiovascular  disease  18 

Different  types  of  cardiovascular  diseases.  Global  deaths  from 
cardiovascular  diseases. 

Rheumatic  fever  and  rheumatic  heart  disease  20 

Deaths  from  rheumatic  heart  disease.  Cases  of  rheumatic  heart 
disease  in  children.  Deaths  among  Aboriginal  and  non- 
Aboriginal  populations  in  Australia. 


Part  Two:  RISK  FACTORS  22 

Risk  factors  24 

Overview  of  modifiable,  non-modifiable  and  "novel"  risk 
factors.  Percentage  contribution  of  leading  risk  factors  to 

o  o 

disease  burden.  Contributory  factors  in  coronary  heart  disease 
and  ischaemic  stroke. 

Risk  factors  start  in  childhood  and  youth  26 

Tobacco  use  in  youth.  Overweight  youth.  Over  weight  trends 
in  the  USA. 

Risk  factor:  blood  pressure  28 

Average  systolic  blood  pressure  worldwide.  Trends  of  high 
blood  pressure  in  USA  and  India.  Changes  in  blood  pressure 
with  age  in  Gambia,  and  with  education  in  South  Africa. 

Risk  factor:  lipids  30 

Cholesterol  levels  in  women  worldwide.  Trends  in  cholesterol 
levels  in  Beijing,  China.  Current  recommended  lipid  levels. 

Risk  factor:  tobacco  32 

Smoking  rates  worldwide.  Cardiovascular  risks  of  smoking  and 
passive  smoking.  Smokers'  lack  of  knowledge  of  the  risks. 


Risk  factor:  physical  inactivity  34 

Physical  activity  levels:  energy  expenditure  in  work,  leisure  and 
transport.  Time  spent  seated.  Various  physical  activities  with 
similar  health  benefits.  Physical  inactivity  by  social  class  in  India. 
Participation  in  sport  in  Singapore.  Motor  vehicle  ownership 
and  trends.  Ratio  of  bicycles  to  cars  in  China  and  USA. 

9  Risk  Factor:  obesity  36 

Average  adult  body  mass  index  (BMI)  worldwide.  Food 
consumption  trends.  Apple  shape  at  higher  risk  of  CVD 
than  pear  shape. 

10  Risk  factor:  diabetes  38 

Prevalence  of  diabetes  worldwide.  Diabetes  trends  to  2030. 

1 1  Risk  factor:  socioeconomic  status  40 

Socioeconomic  influences  on  cardiovascular  risk  factors  and 
diseases.  Education,  income  levels  and  occupation  in  Canada, 
China,  India,  Italy,  Saudi  Arabia,  South  Africa,  Trinidad  and 
Tobago,  Uganda  and  USA. 

o    '        o 

12  Women:  a  special  case?  42 

Similar  and  different  risks  in  women  compared  with  men. 
Smoking,  physical  activity  and  hormone  replacement  therapy. 


Part  Three:       THE  BURDEN  44 

1 3  Global  burden  of  coronary  heart  disease  46 

Healthy  years  of  life  lost  to  coronary  heart  disease.  Leading 
causes  of  disease  burden  by  sex. 

14  Deaths  from  coronary  heart  disease  48 

Deaths  from  coronary  heart  disease.  Comparison  with  other 
causes  of  death.  Trends  in  coronary  heart  disease. 

1 5  Global  burden  of  stroke  50 

Healthy  years  of  life  lost  to  stroke.  Stroke  in  young  people. 
Risks  of  the  oral  contraceptive  pill. 

16  Deaths  from  stroke  52 

Deaths  from  stroke.  Predictors  of  death  from  stroke  in  Italy. 
Comparison  with  other  causes  of  death. 


Economic  costs  54 

Cost  of  cardiovascular  diseases  and  their  risk  factors  in  selected 

countries,  regions  and  worldwide.  Price  of  medications 

o 

compared  with  cheapest  crop  available.  Lifetime  costs  of 
coronary  heart  disease.  Expenditure  on  cardiovascular 
medications.  Cost  of  risk  factors. 


Part  Four:         ACTION  56 

18  Research  58 

Number  of  publications  on  cardiovascular  research  by  country. 
Regional  research.  Clinical  trials  on  humans:  cardiovascular 
disease  compared  with  other  health  problems.  Research  funding 
in  the  USA:  CVD  compared  with  other  diseases. 

Organizations  60 

International  and  regional  organizations  involved  with 

o  o 

cardiovascular  disease.  World  conferences  on  cardiovascular 
diseases. 

Prevention:  personal  choices  and  actions  62 

Personal  choices  in  lifestyles  and  behaviours  in  children, 
adolescents  and  adults:  stopping  smoking,  eating  more  fruit  and 
cereals,  reducing  salt  intake,  physical  activity,  and  prevention 
and  control  of  obesity  and  high  blood  pressure. 

Prevention:  population  and  systems  approaches  64 

Noncommunicable  disease  prevention  and  control.  Availability 
of  basic  equipment,  medical  professionals,  and  availability, 
affordability,  and  local  manufacture  of  drugs.  Use  of 
medications  in  stroke  and  coronary  heart  disease.  Profiles  of 
Finland,  Japan,  Mauritius  and  New  Zealand.  Dieticians  in  the 
United  Kingdom  promote  healthy  eating. 

Health  education  66 

World  Heart  Day  participation,  themes  and  trends.  Medical 
activities,  physical  activities  and  promotion  of  healthy  diet. 
Giving  up  smoking:  the  International  Quit  and  Win  campaign. 

Policies  and  legislation  68 

Smoke-free  government  buildings  and  private  workplaces.  The 
first  five  countries  to  ratify  the  WHO  Framework  Convention 
on  Tobacco  Control  (FCTC).  National  plans  for  CVD 
prevention  and  control.  Tobacco,  food  and  nutrition  legislation. 
Smoking  ban  in  the  USA  led  to  reduction  in  heart  attacks. 


24  Treatment  70 

Medication,  devices,  and  operations.  Simple  secondary 
prevention.  Proportion  of  patients  reaching  blood  pressure  and 
cholesterol  treatment  goals.  Participation  in  cardiac 
rehabilitation.  Proportion  of  people  with  diabetes  treated  with 
medication  or  diet.  Trends  in  cardiovascular  operations  and 
procedures  in  the  USA. 


Part  Five:  THE  FUTURE  AND  THE  PAST  72 

The  future  74 

Predictions  to  2030  of  the  cardiovascular  disease  epidemic,  risk 
factors,  economic  costs,  research,  UN  Conventions,  technology 
and  treatment. 

Milestones  in  knowledge  of  heart  and  vascular  disorders 

History  of  key  events,  developments  and  research,  including 
epidemiology,  risk  factors,  economic  costs,  inventions  and 
interventions. 

BCE-1852  76 

1856-1967  78 

1969-2004  80 


Part  Six:             World  Tables  82 

World  data  tables  84 

Glossary  92 

Sources  94 

Useful  contacts  109 

Index  1 1 1 


Foreword 


A  message  from 

Dr  LEE  Jong-Wook 

Director-  General 

World  Health  Organization 

O 

11  cart  disease  and  stroke  are  currently  the  leading  cause  of  death  in  all  developed  countries  and  in  most  developing 
countries.  There  were  approximately  17  million  deaths  due  to  cardiovascular  disease  in  2003  —  one-third  of  all 
deaths  in  the  world. 

It  is  disturbing  to  note  that  at  least  75%  of  deaths  from  heart  disease  and  stroke  now  occur  in  the  poorer  regions 
of  the  world,  which  also  face  major  threats  from  communicable  diseases.  These  regions  thus  suffer  under  the  so- 
called  "double  burden"  of  disease.  If  preventive  action  is  not  taken  urgently,  heart  disease  and  stroke  —  which  are 
already  major  public  health  problems  —  will  rapidly  advance  across  regions  and  social  classes  to  reach  epidemic 
proportions  worldwide. 

We  know  that  the  major  risk  factors  for  heart  disease  and  stroke  are  high  blood  pressure,  high  blood  cholesterol, 
tobacco  use,  physical  inactivity,  unhealthy  diet  and  obesity.  Many  of  these  risk  factors  result  from  unhealthy  lifestyles. 
These  unhealthy  lifestyle  habits,  which  are  linked  to  urbanization,  often  start  in  childhood  and  youth,  encouraged  by 
the  influence  of  mass  advertising  and  social  pressures.  This  underscores  the  importance  of  targeting  children  and 
young  people  in  all  programmes  that  aim  to  prevent  heart  disease  and  stroke. 

Prevention  and  control  of  heart  disease  and  stroke  in  developing  countries  represent  a  challenging  task.  There  are 
a  number  of  major  barriers  to  progress,  including  lack  of  reliable  epidemiological  information,  inaccessibility  of 
health  care,  shortages  of  trained  manpower  and  resources,  and  misconceptions  about  heart  disease  and  stroke  among 
policy-makers  and  the  public. 

However,  the  good  news  is  that  knowledge  about  the  causes  of  heart  disease  and  stroke  is  growing,  and  various 
countries  are  gaining  experience  in  translating  this  knowledge  into  effective  action. 

I  believe  that  our  efforts  to  control  heart  disease  and  stroke  can  only  succeed  if  they  are  focused  at  country  level. 
Current  WHO  activities  in  this  area  are  based  on  the  WHO  Global  Strategy  for  the  Prevention  and  Control  of 
Noncommunicable  Disease,  which  was  adopted  by  the  World  Health  Assembly  in  2000.  Our  goals  are  to: 

•  provide  guidance  to  countries  on  policy,  legislative  and  financial  measures 
that  can  help  prevent  cardiovascular  disease; 

•  assess  and  track  the  magnitude  of  the  cardiovascular  disease  epidemic  and  its 
social,  economic,  behavioural  and  political  determinants  in  developing  countries; 

•  reduce  cardiovascular  risk  factors  and  their  determinants  and  promote 
cardiovascular  health  for  all  age  groups; 

•  strengthen  the  health  care  of  people  with  cardiovascular  disease  by  developing 
norms  and  guidelines  for  cost-effective  interventions. 


To  achieve  these  goals,  WHO  has  developed  standardized  approaches  to  strengthen  national  surveillance  systems 
for  key  risk  factors.  Further,  WHO  has  initiated  programmes  at  country  level  to  scale  up  health  care  for  those  with 
established  cardiovascular  disease  and  to  introduce  affordable  and  innovative  approaches  for  managing  cardiovascular 
risk  factors  and  cardiovascular  disease  in  low-resource  settings. 

WHO  is  also  in  the  process  of  addressing  some  of  the  main  risk  factors  for  cardiovascular  disease  through  global 
action,  such  as  the  Framework  Convention  on  Tobacco  Control  and  the  Global  Strategy  on  Diet,  Physical  Activity 
and  Health.  These  strategies  will  help  countries  in  their  efforts  to  develop  and  implement  policies  to  reduce  the 
burden  of  cardiovascular  disease. 

We  recognize  that  advocacy,  resource  mobilization,  capacity  development,  and  research  are  necessary  to  galvanize 
global  action  against  the  causes  of  cardiovascular  disease.  WHO  is  working  with  other  UN  agencies,  research 
institutions,  nongovernmental  organizations,  the  private  sector  and  civil  society  to  promote  these  activities.  Together 
we  can  move  the  global  public  health  agenda  forward  to  avert  unnecessary  deaths  and  suffering  due  to  this  eminently 
preventable  disease. 


10 


Preface 


"We  have  the  scientific  knowledge  to  create  a  world 

in  which  most  heart  disease  and  stroke  could  be  eliminated." 

The  Victoria  Declaration  on  Heart  Health,  1992 

"Change  before  you  have  to." 
Jack  Welch, 

former  Chairman  and  Chief  Executive  Officer  of 
General  Electric,  USA  (193 5-) 


lleart  disease  and  stroke,  the  main  cardiovascular  diseases,  are  truly  global  epidemics.  They  deserve  the  attention 
of  governments,  policy-makers,  national  and  international  organizations,  committed  individuals  and  families 
everywhere. 

Heart  disease  and  stroke  are  no  longer  diseases  of  old  men  in  developed  countries.  They  are  also  diseases  of 
women,  young  adults,  and  even  children.  They  affect  the  wealthy  and  the  poor.  Already  they  claim  more  lives  in 
developing  than  developed  countries.  The  Asian  girl  on  the  cover  is  at  risk,  as  are  many  children  and  young  adults 
throughout  the  world. 

o 

The  risk  factors  for  heart  disease  and  stroke  begin  in  youth,  and  most  can  be  prevented  or  controlled.  Yet, 
worldwide,  most  people  who  have  risk  factors  are  either  not  treated  or  are  inadequately  treated.  Special  attention  to 
high  blood  pressure,  high  blood  cholesterol,  tobacco  and  other  major  risk  factors  is  crucial. 

Cardiovascular  diseases  are  more  than  just  health  problems:  both  the  diseases  and  their  underlying  causes  have 
major  financial  implications  for  governments,  businesses  and  individuals.  The  "globesity"  epidemic  is  causing 
international  concern.  The  tobacco  epidemic  is  linked  to  smuggling,  big  business  and  politics.  If  people  are  to  be 
encouraged  to  take  regular  physical  activity,  commitment  is  needed  from  both  individuals  and  society.  The 
prevention  and  control  of  high  blood  pressure  and  high  blood  cholesterol  require  action  from  governments  and  the 
pharmaceutical  industry,  not  just  individual  patients. 

Research  achievements  in  the  field  of  heart  disease  and  stroke  have  been  phenomenal.  We  know  a  lot  today,  but  as 
Goethe  put  it,  "knowing  is  not  enough,  we  must  apply."  We  must  apply  what  we  already  know,  and  translate  the  best 
science  into  practice  for  the  benefit  of  all,  worldwide. 

The  good  news,  as  stated  most  eloquently  in  the  Victoria  Declaration  on  Heart  Health  more  than  a  decade  ago,  is 
that  we  know  what  we  need  to  do  to  eliminate  most  heart  disease  and  stroke.  What  is  needed  now  is  the 
combination  of  necessary  resources  and  political  will  on  a  global  scale  to  take  effective  action.  Now  is  the  time  to  act 
—  and  to  change  before  we  have  to. 


Judith  Mackay,  Hong  Kong  SAR,  China 
George  A.  Mensah,  Atlanta,  GA,  USA 


11 


Acknowledgements 


Special  thanks  go  to  the  following  WHO  staff  for  their 
support  for  this  project:  Catherine  Le  Gales-Camus, 
Assistant  Director-General,  Noncommunicable  Diseases 
and  Mental  Health;  Robert  Beaglehole,  Director, 
Department  of  Chronic  Diseases  and  Health  Promotion; 
Rafael  Bengoa,  Director,  Health  Systems  Policy  and 
Operations;  and  Derek  Yach,  Representative  of  the 
Director-General. 

Particular  thanks  go  to  the  Centers  for  Disease 
Control  and  Prevention  (CDC),  United  States  of 
America,  for  their  generous  financial  support  of  this 
atlas. 

For  their  creativity,  artistic  talent  and  innovative 
suggestions  in  the  design  and  cartography  of  this  atlas, 
we  would  like  to  thank  the  Myriad  Editions  team  of 
Candida  Lacey,  Corinne  Pearlman,  Hay  ley  Ann  and 
Isabelle  Lewis. 

Sincere  thanks  go  to  Pat  Butler  for  her  editorial  input, 
and  to  all  colleagues  at  the  World  Health  Organization: 
Dele  Abepunde,  Technical  Officer,  Cardiovascular 

O 

Diseases,  Noncommunicable  Diseases  and  Mental  Health; 

Timothy  Armstrong,  Technical  Officer, 
Surveillance  and  Information  for  Policy, 
Noncommunicable  Diseases  and  Mental  Health; 

Vishal  Arora,  Noncommunicable  Diseases  and 
Mental  Health,  South  East  Asia  Region  (SEARO); 

Fabienne  Besson,  Secretary,  Management  of 
Noncommunicable  Diseases,  Noncommunicable 
Diseases  and  Mental  Health; 

Ties  Boerma,  Director,  Measurement  and  Health 
Information  Systems,  Evidence  and  Information  for 
Policy; 

Ruth  Bonita,  Director,  Surveillance,  Office  of 
Assistant  Director- General,  Evidence  and  Information 
for  Policy; 

Gian  Luca  Burci,  Senior  Legal  Officer,  Office  of 
the  Legal  Counsel; 

Somnath  Chatter] i,  Scientist,  Classification, 
Assessment,  Surveys  and  Terminology,  Evidence  and 
Information  for  Policy; 

Charles  Gollmar,  Group  Leader,  School  Health 
and  Youth  Health  Promotion,  Noncommunicable 
Diseases  and  Mental  Health; 

Carina  Marquez,  Technical  Officer,  Surveillance 
and  Information  for  Policy,  Noncommunicable  Diseases 
and  Mental  Health; 

Colin  Mathers,  Scientist,  Epidemiology  and 

12 


Burden  of  Disease,  Evidence  and  Information  for  Policy; 

Shanthi  Mendis,  Coordinator,  Cardiovascular 
Diseases,  Noncommunicable  Diseases  and  Mental 
Health; 

Patricia  Mucavele,  Technical  Officer,  Nutrition  for 
Health  and  Development,  Noncommunicable  Diseases 
and  Mental  Health; 

Mona  Nassef,  Secretary,  Cardiovascular  Diseases, 
Noncommunicable  Diseases  and  Mental  Health; 

Chizuru  Nishida,  Scientist,  Nutrition  for  Health 
and  Development,  Noncommunicable  Diseases  and 
Mental  Health; 

Tomoko  Ono,  Technical  Officer,  Surveillance  and 
Information  for  Policy,  Noncommunicable  Diseases  and 
Mental  Health; 

Leanne  Riley,  Scientist,  School  Health  and  Youth 
Health  Promotion,  Noncommunicable  Diseases  and 
Mental  Health; 

Gojka  Roglic,  Technical  Officer,  Diabetes 
Mellitus,  Noncommunicable  Diseases  and  Mental 
Health; 

Jukka  Sailas,  Scientist,  Management  Support 
Unit,  Evidence  and  Information  for  Policy, 
Noncommunicable  Diseases  and  Mental  Health; 

Bakuti  Shengelia,  Medical  Officer,  Cardiovascular 
Diseases,  Noncommunicable  Diseases  and  Mental 
Health; 

Kate  Strong,  Acting  Team  Coordinator, 
Surveillance  and  Information  for  Policy, 
Noncommunicable  Diseases  and  Mental  Health; 

Bedirhan  Ustun,  Coordinator,  Classification, 
Assessment,  Surveys  and  Terminology,  Evidence  and 
Information  for  Policy; 

Pierre-Michel  Virot,  Audiovisual  and  Training 
Team,  Information  Technology  and  Telecommunications; 

Amalia  Waxman,  Project  Manager, 
Noncommunicable  Diseases  and  Mental  Health. 

Thanks  to  our  colleagues  at  the  National  Center  for 
Chronic  Disease  Prevention  and  Health  Promotion, 
Centers  for  Disease  Control  and  Prevention  (CDC), 
United  States  of  America: 

Laurie  D.  Elam-Evans,  Deputy  Associate  Director 
for  Science,  Division  of  Adult  and  Community  Health; 

Wayne  H.  Giles,  Associate  Director  of  Science, 
Division  of  Adult  and  Community  Health; 

Kurt  J.  Greenlund,  Senior  Epidemiologist, 
Science  and  Communication  Unit,  Cardiovascular  Health 


Branch,  Division  of  Adult  and  Community  Health; 

Mary  E.  Hall,  Public  Health  Analyst,  Office  of  the 
Director; 

Virginia  Bales  Harris,  Director,  Division  of  Adult 
and  Community  Health; 

Marsha  L.  Houston,  Health  Communication 
Specialist,  Cardiovascular  Health  Branch,  Division  of 
Adult  and  Communitv  Health; 

Frederick  L.  Hull,  Deputy  Chief,  Technical 
Information  and  Editorial  Services  Branch,  Office  of  the 
Director; 

Margaret  Malone,  Deputy  Chief,  Cardiovascular 
Health  Branch,  Division  of  Adult  and  Community 
Health; 

James  S.  Marks,  Director. 

For  their  input  on  particular  maps  and  subjects,  we 
would  like  to  thank  the  following: 

4  Risk  factors  start  in  childhood  and  youth 
Samira  Asma,  Associate  Director,  Global  Tobacco 
Control,  Office  on  Smoking  and  Health,  Centers  for 
Disease  Control  and  Prevention,  USA;  Jonathan  R. 
Carapetis,  Consultant  in  Paediatric  Infectious  Diseases, 
Centre  for  International  Child  Health,  University  of 
Melbourne,  Australia;  Gilles  Paradis,  Division  of 
Preventive  Medicine,  McGill  University  Health  Center, 
Montreal,  Canada;  Neville  Rigby,  Director  of  Policy  and 
Public  Affairs,  International  Obesity  TaskForce, 
International  Association  for  the  Study  of  Obesity; 
Charles  W.  Warren,  Distinguished  Consultant 
/Demographer,  Global  Tobacco  Control,  Office  on 
Smoking  and  Health,  Centers  for  Disease  Control  and 
Prevention,  USA. 

5  Risk  factor:  blood  pressure  Yussuf  Saloojee, 
tobacco  control  advocate,  South  Africa. 

6  Risk  factor:  lipids  Robert  Clarke,  Clinical  Trial 
Service  Unit,  Oxford  University,  United  Kingdom;  Rory 
Collins,  Clinical  Trial  Service  Unit,  Oxford  University, 
United  Kingdom. 

o 

7  Risk  factor:  tobacco  Omar  Shafey,  Manager, 
International  Tobacco  Surveillance,  American  Cancer 
Society,  USA. 

8  Risk  factor:  physical  inactivity  Krishnan  Anand, 
Associate  Professor,  Centre  for  Community  Medicine, 
All  India  Institute  of  Medical  Sciences,  India. 

12  Women:  a  special  case?  Sandra  Coney,  women's 

health  advocate,  New  Zealand. 

18   Research  Rory  Collins,  Clinical  Trial  Service  Unit, 


Oxford  University,  United  Kingdom;  Hugh  Tunstall- 
Pedoe,  Cardiovascular  Epidemiology  Unit,  University  of 
Dundee,  United  Kingdom  (MONICA  study). 
19  Organizations  Children's  Heart  Link  (USA):  Karen 
Baumgaertner,  International  Programs  Associate;  John 
Gushing,  International  Programs  Director.  International 
Association  for  the  Study  of  Obesity:  Neville  Rigby,  Director 
of  Policy  and  Public  Affairs,  International  Obesity 
TaskForce.  International  Stroke  Society:  Julien 
Bogousslavsky,  President-Elect;  Frank  M.  Yatsu, 
Treasurer.  World  Heart  Federation:  Carola  Adler,  World 
Heart  Day  Manager;  Sara  Bowen,  Website /IT  Manager; 
Sania  Nishtar,  Chairman,  World  Heart  Day  Committee; 
Philip  Poole-Wilson,  President;  Janet  Voute,  Chief 
Executive  Officer. 

22  Health  education  World  Heart  Federation  (as 
above);  Eeva  Riitta  Vartiainen,  Project  Manager, 
International  Quit  and  Win,  Finland. 

23  Policies  and  legislation  Omar  Shafey,  Manager, 
International  Tobacco  Surveillance,  American  Cancer 
Society,  USA. 

25  The  future  Rory  Collins,  Clinical  Trial  Service 
Unit,  Oxford  University,  United  Kingdom;  Anthony 
Rodgers,  Clinical  Trials  Research  Unit,  University  of 
Auckland,  New  Zealand. 

26  Chronology  Julien  Bogousslavsky,  President-Elect, 
International  Stroke  Society;  Rory  Collins,  Clinical  Trial 
Service  Unit,  Oxford  University,  United  Kingdom;  John 
W.  Farquhar,  Stanford  Prevention  Research  Center, 
USA;  David  Simpson,  International  Agency  on  Tobacco 
and  Health,  London,  United  Kingdom. 

We  are  also  extremely  grateful  to  our  families  for  their 
support  during  the  preparation  of  this  atlas. 

For  the  use  of  photographs,  we  would  like  to  thank  the 

following: 

Front  cover  Amy,  Hong  Kong  ©  Guy  Nowell,  Hong 

Kong  SAR,  China,  http://www.guynowell.com 

Back  cover  photographs   Cardiology  operation, 

Mauritius  ©  WHO /Harry  Anenden;  man  selling 

vegetables,  India  ©  WHO /Pierre  Virot;  man  on  bench 

©  iStock/Tomaz  Levstek;  Woman  and  girl  buying 

sweets,  India  ©  WHO/Pierre  Virot 

Part  1    Child  health  examination,  Cuba  © 

WHO /Carlos  Gaggero 

Part  2  Woman  cooking,  Guatemala  ©  WHO/Armando 

Waak 

13 


Part  3  Cardiology  operation,  USA  ©  WHO/Jean 

Mohr 

Part  4  Youth  sport,  Germany  ©  WHO/Tibor  Farkas 

Part  5  Adolescent  group,  Peru  ©  WHO /Julio  Vizcarra 

Part  6  Man  selling  vegetables,  India  ©  WHO/Pierre 

Virot 

I  Types  of  cardiovascular  disease  Heart  ©  Hemera 
Photo-Objects 

4  Risk  factors  start  in  childhood  and  youth  Boy 

smoking,  Seychelles  ©  WHO/Harry  Anenden;  burger 
©  Hemera  Photo-Objects 

6  Risk  factor:  lipids  Arteries  ©  American  Heart 
Association;  rice  bowl  ©  Hemera  Photo-Objects 

7  Risk  factor:  tobacco  Smoking  hand;  young  people, 
Canada  ©  WHO/J  L  Ray;  road  signs,  USA  ©  Corinne 
Pearlman 

8  Risk  factor:  physical  inactivity  TV  viewer,  biker, 
wheelchair  user,  woman  with  push-chair  ©  Hemera 
Photo-Objects;  people  on  scooter,  New  Delhi  © 
Candida  Lacey 

9  Risk  factor:  obesity  Groceries,  USA  ©  USDA/ 
Ken  Hammond;  apple  and  pear  ©  Woodrow  Phoenix/ 
Comic  Company /British  Dietetic  Association 

10  Risk  factor:  diabetes  Men  playing  basketball, 
Finland  ©  WHO /Farkas  Tibor 

I 1  Risk  factor:  socioeconomic  status  Young  boy 
smoking,  China  ©  Carol  Betson 

12  Women:  a  special  case?  Hospital  patient,  Finland 
©  WHO/Tibor  Farkas;  smoking  woman  ©  iStock/ 
Tan  Kian  Khoon;  obese  woman  ©  iStock/Annette 
Birkenfeld;  women  walking  ©  iStock/ Leah- Anne 
Thompson;  menopausal  woman  ©  iStock/Joseph  Jean 
Rolland  Dube 

13  Global  burden  of  coronary  heart  disease 
Cardiology  operation,  Mauritius  ©  WHO/Harry 
Anenden 


14  Deaths  from  coronary  heart  disease 

Cardiology  operation,  USA  ©  WHO/Jean  Mohr;  heart 
©  Hemera  Photo-Objects 

15  Global  burden  of  stroke  Pills  ©  iStock/ Amanda 
Rohde 

16  Deaths  from  stroke  Man  on  bench  ©  iStock/ 
Tomaz  Levstek 

17  Economic  costs  Rice  ©  USDA /Ken  Hammond; 
potatoes  ©  USDA/Ken  Hammond 

19  Organizations  WHO  HQ  Geneva  © 
WHO/Pierre  Virot 

20  Prevention:  personal  choices  and  actions 
Salad,  USA  ©  Corinne  Pearlman;  Amv,  Hong  Kong  © 

J  '  O  O 

Guy  Nowell;  grapefruit,  runner  ©  Hemera  Photo- 
Objects 

21  Prevention:  population  and  systems 
approaches  Good  Heart  Food  leaflet  ©  British 
Dietetic  Association/ Comic  Company;  hospital 
computer,  UK  ©  WHO/P  Larsen;  health  examination 
©  WHO /Julio  Vizcarra 

22  Health  Education  Posters  ©  World  Heart 
Federation 

23  Policies  and  legislation  Singapore  bus  ©  WHO/ 
Tibor  Farkas;  display,  gymnasium,  Singapore,  ©  WHO; 
fried  food,  USA  (bar  chart)  ©  Corinne  Pearlman;  man 
smoking,  Sri  Lanka  (bar  chart)  ©  Garrett  Mehl;  burger 
©  Hemera  Photo-Objects 

24  Treatment  Man  on  bike,  Finland  ©  WHO/Tibor 
Farkas 

25  The  future  Woman,  Rwanda  ©  WHO/J.  L.  Ray 


Whilst  every  reasonable  effort  has  been  made  to  contact 
the  copyright  holders  of  images  used  in  the  atlas,  the 
authors  and  publisher  will  gladly  receive  information 
that  will  enable  them  to  rectify  any  inadvertent  errors  in 
subsequent  editions. 


14 


About  the  authors 


Dr  Judith  Mackay 
MBChB,  FRCP  (Edin),  FRCP  (Eng) 

Dr  Judith  Mackay  is  a  medical  doctor  based  in  Hong 

Kong  Special  Administrative  Region,  China,  and  a 

Senior  Policy  Adviser  to  the  World  Health  Organization. 

After  an  early  career  as  a  hospital  physician,  she  became 

a  health  advocate.  She  is  a  Fellow  of  the  Royal  Colleges 

of  Physicians  of  Edinburgh  and  of  London,  and  an 

Honorary  Fellow  of  the  Hong  Kong  College  of 

Cardiology.  Dr  Mackay  has  received  many  international 

awards,  including  the  WHO  Commemorative  Medal, 

the  Fries  Prize  for  Improving  Health,  the  Luther  Terry 

Award  for  Outstanding  Individual  Leadership,  the 

International  Partnering  for  World  Health  Award,  and 

the  Founding  International  Achievement  Award  from  the 

Asia  Pacific  Association  for  the  Control  of  Tobacco. 

She  is  the  author  of  The  Tobacco  Atlas,  The  State  of  Health 

Atlas  and  The  Penguin  Atlas  of  Human  Sexual  Behavior. 


Dr  George  A.  Mensah 
MD,  FACC,  FACP,  FESC 

Dr  George  Mensah  is  acting  director,  the  National 

Center  for  Chronic  Disease  Prevention  and  Health 

Promotion,  and  chief  of  the  Cardiovascular  Health 

Branch  at  the  Centers  for  Disease  Control  and 

Prevention  in  Atlanta,  Georgia,  USA,  and  clinical 

professor  of  medicine  and  cardiology  at  the  Medical 

College  of  Georgia.  He  is  a  fellow  of  the  American 

College  of  Cardiology,  American  Heart  Association, 

and  the  European  Society  of  Cardiology,  and  a 

foundation  fellow  of  the  Ghana  College  of  Physicians 

and  Surgeons.  Recent  honours  include  the 

Distinguished  Research  Award  of  the  International 

O 

Society  of  Hypertension  in  Blacks,  the  25th  Bernard 

Pimstone  Memorial  Lecturer  at  the  University  of  Cape 

Town  in  South  Africa,  and  the  National  Heart 

Foundation  of  Australia  Lecturer  at  the 

50th  Anniversary  Celebration  of  the  Cardiac 

Societies  of  Australia  and  New  Zealand. 


15 


16 


PART  1 

CARDIOVASCULAR  DISEASE 


"When  man  is  serene,  the  pulse  of  the  heart  flows  and  connects, 
just  as  pearls  are  joined  together  or  like  a  string  of  red  jade, 

then  one  can  talk  about  a  healthy  heart." 

17 

The  Yellow  Emperor's  Canon  of  Internal  Medicine,  2500  BCE 


1 


"All  the  knowledge  I  possess  everyone  else 

can  acquire,  but  my  heart  is  all  my  own." 

Johann  Wolfgang  von  Goethe 

The  Sorrows  of  Young  Werther  1774 

The  human  heart  is  only  the  size 
of  a  fist,  but  it  is  the  strongest 
muscle  in  the  human  body. 

The  heart  starts  to  beat  in  the 
uterus  long  before  birth,  usually 
by  21  to  28  days  after  conception. 
The  average  heart  beats  about 

O 

1 00  000  times  daily  or  about  two 
and  a  half  billion  times  over  a 
70  year  lifetime. 

With  every  heartbeat,  the  heart 
pumps  blood  around  the  body.  It 
beats  approximately  70  times  a 
minute,  although  this  rate  can 

O 

double  during  exercise  or  at  times 
of  extreme  emotion. 

Blood  is  pumped  out  from  the 
left  chambers  of  the  heart.  It  is 
transported  through  arteries  of 
ever-decreasing  size,  finally 
reaching  the  capillaries  in  all  the 
tissues,  such  as  the  skin  and  other 
body  organs.  Having  delivered  its 
oxygen  and  nutrients  and  having 
collected  waste  products,  blood  is 
brought  back  to  the  right 

O  O 

chambers  of  the  heart  through  a 
system  of  ever-enlarging  veins. 
During  the  circulation  through 
the  liver,  waste  products  are 
removed. 

This  remarkable  system  is 
vulnerable  to  breakdown  and 
assault  from  a  variety  of  factors, 
many  of  which  can  be  prevented 
and  treated.  Risk  factors  will  be 
explored  on  pages  24 — 43. 


Types  of  cardiovascular 
disease 


2  265  824 


Deaths  from  cardiovascular  diseases  (CVD) 

Number  of  deaths  globally  per  year 
from  different  types  of  CVD, 

bY  age  / 1868  339 

Highest  numbers  shown 

2002 


coronary  heart  disease 

stroke 

other  cardiovascular  diseases 

hypertensive  heart  disease 

inflammatory  heart  disease 

rheumatic  heart  disease 


996  183 


280819 


104  116 


66542 


0-4  years          5-14  15-29  30-44  45-59  60-69  70-79         80+ years 


Global  deaths  from  CVD 

millions 

2002 

total  deaths:  16.7  million 


other  forms  of 

heart  disease 

2.4m 


inflammatory 
heart  disease 
0.4m 

hypertensive 
heart  disease 
0.9m 

rheumatic 
heart  disease 
0.3m 

18 


coronary  heart  disease 
7.2m 


Coronary  heart  disease 

Disease  of  the  blood  vessels 

supplving  the  heart  muscle. 

Major  risk  factors  High  blood  pressure, 

high  blood  cholesterol,  tobacco  use, 

unhealthy  diet,  physical  inactivity, 

diabetes,  advancing  age,  inherited 

(genetic)  disposition. 

Other  risk  factors  Poverty,  low  educational 

status,  poor  mental  health  (depression), 

inflammation  and  blood  clotting  disorders. 

Rheumatic  heart  disease 

Damage  to  the  heart  muscle  and  heart 
valves  from  rheumatic  fever,  caused  by 
streptococcal  bacteria.       J— ^— •— • 


Congenital  heart  disease 

Malformations  of  heart  structures 
existing  at  birth  may  be  caused  bv 

o  -*  * 

genetic  factors  or  by  adverse 

exposures  during  gestation. 

Examples  are  holes  in  the 

heart,  abnormal  valves, 

and  abnormal  heart 

chambers. 

Riskfactors 

Maternal  alcohol 

use,  medicines 

(for  example 

thalidomide,  warfarin)  used  by  the  expectant 

mother,  maternal  infections  such  as  rubella, 

poor  maternal  nutrition  (low  intake  of  folate), 

close  blood  relationship  between  parents 

(consanguinity). 

Other  cardiovascular  diseases 

Tumours  of  the  heart;  vascular  tumours  of  the 
brain;  disorders  of  heart  muscle 
(cardiomyopathy);  heart  valve  diseases; 
disorders  of  the  lining  of  the  heart. 

Other  factors  that  can  damage 
the  heart  and  blood  vessel  system 

Inflammation,  drugs,  high  blood  pressure, 
unhealthy  diet,  trauma,  toxins  and  alcohol. 


Stroke 

Strokes  are  caused  by  disruption  of  the  blood  supply  to  the 

brain.  This  may  result  from  either  blockage  (ischaemic 

stroke)  or  rupture  of  a  blood  vessel  (haemorrhagic  stroke). 

Riskfactors  High  blood  pressure,  atrial  fibrillation  (a  heart 

rhythm  disorder),  high  blood  cholesterol,  tobacco  use, 

unhealthy  diet,  physical  inactivity,  diabetes, 

and  advancing  age. 


Aortic  aneurysm  and 
dissection 

Dilatation  and  rupture 
of  the  aorta. 

Riskfactors  Advancing  age,  long- 
L   standing  high  blood  pressure, 
Mar  fan  syndrome, 
congenital  heart  disorders, 

o 

syphilis,  and  other 
infectious  and 
inflammatory 
disorders. 


Peripheral  arterial  disease 

Disease  of  the  arteries 
supplying  the  arms  and  legs. 
Riskfactors  As  for 
coronary  heart  disease. 

Deep  venous  thrombosis  (DVT) 
and  pulmonary  embolism 

Blood  clots  in  the  leg  veins, 
which  can  dislodge  and  move  to  the 

O 

heart  and  lungs. 

Riskfactors  Surgery,  obesity,  cancer, 
previous  episode  of  DVT,  recent 
childbirth,  use  of  oral  contraceptive  and 
hormone  replacement  therapy,  long 
periods  of  immobility, 
for  example  while  travelling,  high 
homocysteine  levels  in  the  blood. 

19 


Rheumatic  fever  usually  follows 
an  untreated  beta-haemolytic 
streptococcal  throat  infection  in 
children.  It  can  affect  many  parts 
of  the  body,  and  may  result  in 
rheumatic  heart  disease,  in  which 
the  heart  valves  are  permanently 
damaged,  and  which  may  progress 
to  heart  failure,  atrial  fibrillation, 
and  embolic  stroke. 

Nowadays,  rheumatic  fever 
mostly  affects  children  in 
developing  countries,  especially 
where  poverty  is  widespread.  Up 
to  1  %  of  all  schoolchildren  in 
Africa,  Asia,  the  Eastern 
Mediterranean  region  and  Latin 
America  show  signs  of  the 

o 

disease. 

Of  1 2  million  people  currently 
affected  by  rheumatic  fever  and 
rheumatic  heart  disease,  two- 
thirds  are  children  between 
5  and  15  years  of  age.  There  are 
around  300  000  deaths  each  year, 
with  two  million  people  requiring 
repeated  hospitalization  and  one 
million  likely  to  require  surgery 
in  the  next  5  to  20  years. 

Early  treatment  of 
streptococcal  sore  throat  can 
preclude  the  development  of 
rheumatic  fever.  Regular  long- 
term  penicillin  treatment  can 
prevent  rheumatic  fever 
becoming  rheumatic  heart 
disease,  and  can  halt  disease 
progression  in  people  whose  heart 
valves  are  already  damaged  by  the 
disease.  In  many  developing 
countries,  lack  of  awareness  of 
these  measures,  coupled  with 
shortages  of  money  and 
resources,  are  important  barriers 
to  the  control  of  the  disease. 


Rheumatic  fever  and 
rheumatic  heart  disease 


EL  SALVADOI 

COSTA  Rl 


I(JRAS  ST  KinS  a  NEVIS         |  ANTIGUA  a  BARBUDA 

ST  VINCENT  a  GRENADINES     (5ST  LJ^A  A 

.i^f  GRENADA  o    O  BARBADOS 

01%^*   ^H  '^TRINIDAD  a  TOBAGO 

PANAMA^!  VENEZUELA      miYAN;A 

COLOMBIA 


MA 

CAPE  VERDE 

SEr 
GAMBIA 

GUINEA-BISSAL 
SIERRA 


Deaths  from  rheumatic  fever  and 
rheumatic  heart  disease  in  the  Aboriginal  * 
and  non-Aboriginal  populations  of  Australia 


1979-1996 


Average  age  at  death 

Aboriginal 
population    3 

non-Aboriginal 
population 


Percentage  of  deaths 


67  Years 


20 


Deaths  from  rheumatic  heart  disease 


Number  of  deaths 

2002 

• 

10  000  and  above 

H    500-999 

0-9 

• 

5000-9999 

100-499 

no  data 

•1 

1000-4999 

|    10-99 

H£EA        YEMEN 

oun 


5 

^•jyr  KENYA 

DEM.  REP.  RIVANDA 


Rheumatic  heart  disease  in  children 

Estimated  number  of  cases  in  5  to  14-year-olds 
reported  2003 


136971  153679 


Sub-Saharan 

Africa 


China         South-Central          Asia 
Asia  (other) 


Latin  America        Eastern  Eastern 

Mediterranean        Europe 
and  North  Africa 


Pacific  Developed 

countries 


21 


/„* 


PART  2 


RISK  FACTORS 


"He  that  eats  but  one  dish  seldom  needs  the  doctor." 

Old  Scottish  proverb 


23 


"The  gods  are  just,  and  of  our  pleasant  vices 

Make  instruments  to  plague  us." 

King  Lear,  V.iii.  193  William  Shakespeare 

(1564-1616) 

Over  300  risk  factors  have  been 
associated  with  coronary  heart 
disease  and  stroke.  The  major 
established  risk  factors  meet  three 
criteria:  a  high  prevalence  in  many 
populations;  a  significant 
independent  impact  on  the  risk  of 
coronary  heart  disease  or  stroke; 
and  their  treatment  and  control 
result  in  reduced  risk. 

Risk  factors  for  cardiovascular 
disease  are  now  significant  in  all 
populations.  In  the  developed 
countries,  at  least  one-third  of  all 
CVD  is  attributable  to  five  risk 
factors:  tobacco  use,  alcohol  use, 
high  blood  pressure,  high 
cholesterol  and  obesity. 

In  developing  countries  with  low 
mortality,  such  as  China, 
cardiovascular  risk  factors  also 
figure  high  on  the  top  10  list. 
These  populations  face  a  double 
burden  of  risks,  grappling  with  the 
problems  of  undernutrition  and 
communicable  diseases,  while  also 
contending  with  the  same  risks  as 
developed  nations. 

Even  in  developing  countries 
with  high  mortality,  such  as  those 
in  sub-Saharan  Africa,  high  blood 
pressure,  high  cholesterol,  tobacco 
and  alcohol  use,  as  well  as  low 
vegetable  and  fruit  intake,  already 
figure  among  the  top  risk  factors. 

Some  major  risks  are  modifiable 
in  that  they  can  be  prevented, 
treated,  and  controlled.  There  are 
considerable  health  benefits  at  all 
ages,  for  both  men  and  women,  in 
stopping  smoking,  reducing 
cholesterol  and  blood  pressure, 
eating  a  healthy  diet  and  increasing 
physical  activity. 

24 


Risk  factors 


high  blood  pressure 
tobacco  use 
high  cholesterol 


Leading  risk  factors 

As  percentage  burden  of  all  diseases 
2002 

major  CVD  risk  factors     • 
other  risk  factors 


10.2%    unsafe  sex 

5.5%    unsafe  water,  sanitation  ft  hygiene 
indoor  smoke  from  solid  fuels 
3.2%    zinc  deficiency 
iron  deficiency 
3.0%    vitamin  A  deficiency 


High-mortality  developing  countrie 


high  blood  pressure 
tobacco  use 
|  high  cholesterol 

alcohol 
obesity 

low  fruit  ft  vegetable  intake 
3.1%    underweight 
1 .9%    indoor  smoke  from  solid  fuels 
1.8%    iron  deficiency 
1.7%    unsafe  water,  sanitation  ft  hygiene 


Jjsjr  * 
Low-mortality  developing  countrie 


9%    high  blood  pressure 

12.2%  tobacco  use 
7.6%  high  cholesterol 
9.2%    alcohol 
obesity 

I  low  fruit  ft  vegetable  intake 
[  physical  inactivity 
1.8%    illicit  drug  use 
0.8%  unsafe  sex 
0.7%  iron  deficiency 


eveloped  countrie 


Contributory  factors 

Percentage  contribution  of  selected  risk  factors 
to  coronary  heart  disease  and  ischaemic  stroke 
2002 


62% 


56% 


^p  low  frui 
physical 

31% 

ll    ll. 


M  suboptimal  systolic 
blood  pressure 
more  than  115  mmHg 

high  cholesterol 
low  fruit  ft  vegetable  intake 
inactivity 


coronary  heart  disease  ischaemic  stroke 


Major  modifiable  risk  factors 

•  High  blood  pressure 

Major  risk  for  heart  attack  and  the  most  important 
risk  factor  for  stroke. 

•  Abnormal  blood  lipids 

High  total  cholesterol,  LDL-cholesterol  and 
triglyceride  levels,  and  low  levels  of  HDL- 
cholesterol  increase  risk  of  coronary  heart  disease 
and  ischaemic  stroke. 

•  Tobacco  use 

Increases  risks  of  cardiovascular  disease,  especially 
in  people  who  started  young,  and  heavy  smokers. 
Passive  smoking  an  additional  risk. 

O 

•Physical  inactivity 
Increases  risk  of  heart  disease  and  stroke  by  50%. 


75% 


of 


C0 


•Obesity 

Major  risk  for  coronary  heart 

disease  and  diabetes. 
•Unhealthy  diets 

Low  fruit  and  vegetable 

intake  is  estimated  to  cause 

about  3 1  %  of  coronary 

heart  disease  and  1 1  %  of 

stroke  worldwide;  high  saturated  fat  intake 

increases  the  risk  of  heart  disease  and  stroke  through 

its  effect  on  blood  lipids  and  thrombosis. 
•  Diabetes  mellitus 

Major  risk  for  coronary  heart  disease  and  stroke. 


ely 


ar 


to 


Other  modifiable  risk  factors 

•  Low  socioeconomic  status  (SES) 

Consistent  inverse  relationship  with  risk  of  heart 
disease  and  stroke. 

•  Mental  ill-health 

Depression  is  associated  with  an  increased  risk  of 
coronary  heart  disease. 

•  Psychosocial  stress 

Chronic  life  stress,  social  isolation  and  anxiety 
increase  the  risk  of  heart  disease  and  stroke. 


Non-modifiable  risk  factors 

•Advancing  age 

Most  powerful  independent  risk  factor  for 
cardiovascular  disease;  risk  of  stroke  doubles 
every  decade  after  age  55. 
•  Heredity  or  family  history 
Increased  risk  if  a  first-degree  blood  relative  has 
had  coronary  heart  disease  or  stroke  before  the 
age  of  55  years  (for  a  male  relative)  or  65  years 
(for  a  female  relative). 


•Alcohol  use 

One  to  two  drinks  per  day  may  lead  to  a  30% 
reduction  in  heart  disease,  but  heavy  drinking 
damages  the  heart  muscle. 

•Use  of  certain  medication 

Some  oral  contraceptives  and  hormone 

replacement  therapy  increase  risk  of  heart  disease. 
1  Lipoprotein(a) 

Increases  risk  of  heart  attacks  especially  in 

presence  of  high  LDL-cholesterol. 
•  Left  ventricular  hypertrophy  (LVH) 

A  powerful  marker  of  cardiovascular  death. 


1  Gender 

Higher  rates  of  coronary  heart  disease  among  men 
compared  with  women  (premenopausal  age);  risk 
of  stroke  is  similar  for  men  and  women. 
1  Ethnicity  or  race 

Increased  stroke  noted  for  Blacks,  some  Hispanic 
Americans,  Chinese,  and  Japanese  populations. 
Increased  cardiovascular  disease  deaths  noted  for 
South  Asians  and  American  Blacks  in  comparison 
with  Whites. 


"Novel"  risk  factors 

•Excess  homocysteine  in  blood 

High  levels  may  be  associated  with  an  increase  in 

cardiovascular  risk. 
•  Inflammation 

Several  inflammatory  markers  are  associated  with 

increased  cardiovascular  risk,  e.g.  elevated 

O 

C-reactive  protein  (CRP). 


•  Abnormal  blood  coagulation 
Elevated  blood  levels  of  fibrinogen  and  other 
markers  of  blood  clotting  increase  the  risk  of 
cardiovascular  complications. 


25 


"Encased  in  fat  in  youth,  encased  in  a 

coffin  in  middle  age." 

Ancient  Chinese  proverb 

Although  cardiovascular  diseases 
typically  occur  in  middle  age  or 
later,  risk  factors  are  determined 
to  a  great  extent  by  behaviours 
learned  in  childhood  and 
continued  into  adulthood,  such  as 
dietary  habits  and  smoking. 

Throughout  the  world,  these 
risks  are  starting  to  appear  earlier. 
Physical  activity  decreases 
markedly  in  adolescence, 
particularly  in  girls.  Obesity  has 
increased  substantially,  not  only 
in  Europe  and  North  America, 
but  also  in  traditionally  slender 
populations  such  as  the  Chinese 
and  Japanese.  Type  2  diabetes  was 
previously  rare  in  children,  but  is 
increasing  in  adolescents  in,  for 
example,  North  America,  Japan 
and  Thailand. 

Markers  of  CVD  can  be  seen  in 
young  children.  Post-mortems  of 
children  who  died  in  accidents 
have  found  fatty  streaks  and 
fibrous  plaques  in  the  coronary 
arteries.  These  early  lesions  of 
atherosclerosis  were  most 
frequently  found  in  children 
whose  risk  factors  included 
smoking,  elevated  plasma  lipids, 
high  blood  pressure  and  obesity. 

Programmes  to  address 
childhood  and  youth  risk  factors 
are  mostly  confined  to  developed 
countries,  but  urgent  action  is 
required  worldwide.  Families, 
schools,  communities,  health 
professionals,  public  health 
officials  and  policy-makers  all 
need  to  promote  healthy  lifestyles 
in  children  and  young  people. 
Unless  the  spread  of  risk  factors  is 
stemmed,  the  world  faces  an 
epidemic  of  CVD. 

26 


Risk  factors  start  in 
childhood  and  youth 


Both  sexes  aged  6  to  1 1  years 
6.5°/o 


Both  sexes  aged  12  to  19  years 


5.0% 


1 0.5% 


Overweight  trends  in  the  USA 

Percentage  of  young  people 
who  are  overweight 
7976-2000 


Overweight  youth 

Percentage  of  15-year-olds 
who  are  overweight 
7997-7998 

selected  countries 

5.1% 
W     males 


^0     females 


10.8% 


Belgium 
(Flemish) 
zech 
public 
Denmark 


f 


o-o 

RUS5IAN    FEDERATION 


CUBA 

MEXICO        HK^^^B 

JAMAICA     ,  \ 
BELIZE 

GUATEMALA  'r.^Sft  NEVIS 

ELSAIVAOOR      •    \DURAS  ST  VINCENT  ft  _    .  -SUTJCIA 

COSTA  RICA  GRENADA         nuKMO  ft  TOBAGO 

PANAMA  VENEZUELA  GUYANA 

COLOMBl 
F     4 


•UNISIA  LEBANON'    "'         ^        IS1.  REp, 

WEST  BANk"*"     JORDAN 
LIBYAN    AND  GAZA 
ARAB 
JAMAHIRIYA         EGYPT 


V 


BAHAMAS 
MEXICO  CU6* 

^JAMAICA      ^         7GANT'luA>;ftB.!.BUDA 

GUATEMALA          x     \       ST  POTS  fl  NEVIS     v  ^unNTSfRRAI  |UK1 
EL  SALVADOR     hONBURAS    S^J™E^-       ST  LUCIA 

COSTARICA  GRENADA       IRINIDAD  ft  TOBAGO 

PANAMA  VENEZUELA  GUYANA 

COLOMBIA        T  SL'RINAME 

ECUADOR 


TUNISIA  LEBANON-  ISl.  REP 

MOROCCO  j-  IRAN 

WEST  BANK       JORDAN 
LIBYAN     AND  GAZA  KUWAIT 

ARAB  BAHRAIN^ 

JAMAHIRIYA        EOYPI 


MAURITl 

'  ^X%v 
SENEGAL 


TANIA 


% 


NIGER 
NIGERIA 


Early  starters 

Percentage  of  students,  primarily  aged  13  to  15  years, 

using  tobacco 

7999-2003 


45%  and  above 
300/0-44.9% 
15%-29.9% 
below  1 5% 
no  data 


. 

^ 


^™°£  ^ — .   ^ 

I-      MYANMAR       l^S 

OO  -< 

^J 

CAMBODIA       VIETNAM    PHILIPPINES 
SRI  LANKA  PALflu, 


N   D   0   N   E   S 


Girls 


ZIMBABWE 


oooo 

<>         URUGUAY 
ARGENTINA 


SWAZILAND 
SOUTH 
AFRICA     LESOTHO 


27 


"There  are  six  flavours  and,  of  them  all, 

salt  is  the  chief." 

Hindu  proverb 

High  blood  pressure 
(hypertension)  is  one  of  the  most 
important  preventable  causes  of 
premature  death  worldwide. 
Even  a  blood  pressure  at  the  top 
end  of  the  normal  range  increases 
risk.  High  blood  pressure  is 
defined  as  a  systolic  blood 
pressure  (SBP)  above  140  mmHg 
and/or  a  diastolic  blood  pressure 
(DBF)  above  90  mmHg. 

In  most  countries,  up  to  30%  of 
adults  suffer  from  high  blood 

O 

pressure  and  a  further  50%  to 
60%  would  be  in  better  health  if 
they  reduced  their  blood 
pressure,  by  increasing  physical 
activity,  maintaining  an  ideal  body 
weight  and  eating  more  fruits  and 
vegetables . 

O 

In  people  aged  up  to  SO  years, 
both  DBF  and  SBP  are  associated 
with  cardiovascular  risk;  above 
this  age,  SBP  is  a  far  more 
important  predictor.  Blood 
pressure  usually  rises  with  age, 
except  where  salt  intake  is  low, 
physical  activity  high,  and  obesity 
largely  absent. 

Most  natural  foods  contain  salt, 
but  processed  food  may  be  high  in 
salt;  in  addition,  individuals  may 
add  salt  for  taste.  Dietary  salt 
increases  blood  pressure  in  most 
people  with  hypertension,  and  in 
about  a  quarter  of  those  with 
normal  blood  pressure,  especially 
with  increasing  age.  A  high  intake 
of  salt  independently  increases  the 
risk  of  CVD  in  overweight 
persons. 

In  addition  to  lifestyle  changes, 
effective  medication  is  available 
for  control  of  high  blood  pressure. 

28 


Risk  factor:  blood 


pressure 


Black  non-Hispanic  female 
Black  non-Hispanic  male 

White  non-Hispanic  male 


White  non-Hispanic  female 

Mexican  male  125.6 
Mexican  female   22. 


igh  blood  pressure  in  the  USA 

Percentage  of  people  aged  20  to  74  years 
with  blood  pressure  of  140/90  mmHg  or  above, 
or  taking  anti-hypertensive  medicine, 
age-adjusted 
/  976-2000 


1988-1994 


1999-2000 


Blood  pressure  changes  with  age  in  the  Gambia 

7996-7997 


\   \ 

16-24         26-35          36-45 
years          years  years 


46-55          56-65 
years  years 


66-75        76-100 
years          years 


High  blood  pressure 
by  years  of  education 
HI  I  in  South  Africa 

Percentage  of  people 
aged  15  and  above 
with  blood  pressure 
higher  than 
160/95  mmHg 
7998 
female 


Blood  pressure  in  India 

Average  systolic  blood  pressure 

in  urban  men 

aged  40  to  49  years 

7942-7997 

mmHg 


Average  systolic  blood  pressure  of  people 
:     aged  30  years  and  above 
estimated  to  2005 

mmHg 

•  data  from  urban  populations  only 


Risk  factor:  lipids 


High  levels  of  LDL-cholesterol, 

o 

and  other  abnormal  lipids  (fats), 
are  risk  factors  for  cardiovascular 
disease.  Cholesterol  is  a  soft, 
waxy  substance  found  among  the 
lipids  in  the  bloodstream  and  in 
all  the  body's  cells.  It  is  needed  to 
form  cell  membranes  and 
hormones,  and  for  other  bodily 
functions. 

The  body  can  make  cholesterol, 
or  it  can  obtain  it  from  food, 
especially  animal  products  such  as 
meats,  poultry,  fish,  eggs,  and 
dairy  products.  Certain  saturated 
vegetable  fats  and  oils,  including 
coconut  fat  and  palm  oil,  are 
cholesterol -free  but  cause  an 
increase  in  blood  cholesterol. 
Some  foods  that  do  not  contain 
animal  products  may  contain 
trans-fats,  which  also  cause  the 
body  to  make  more  cholesterol. 
Fruit,  vegetables  and  cereals  do 
not  contain  cholesterol . 

Cholesterol  is  transported 
around  the  body  in  two  kinds  of 
lipoproteins:  low-density 
lipoprotein,  or  LDL,  and  high- 
density  lipoprotein,  or  HDL. 
A  high  level  of  LDL  can  lead  to 
clogging  of  the  arteries, 
increasing  the  risk  of  heart  attack 
and  ischaemic  stroke,  while  HDL 
reduces  the  risk  of  coronary  heart 
disease  and  stroke. 

The  female  sex  hormone 
estrogen  tends  to  raise  HDL- 
cholesterol  levels,  which  may 
help  explain  why  premenopausal 
women  are  relatively  protected 
from  developing  coronary  heart 
disease. 


Current  recommended  lipid  levels 

European  guideline 

less  than  5.0  mmol/l 
less  than  3.0  mmol/l 


Total  cholesterol 

LDL-cholesterol 

HDL-cholesterol 


US  guideline 

less  than  240  mg/dl  (6.2  mmol/l) 

less  than  160  mg/dl  (3.8  mmol/l) 


1.0  mmol/l  or  more  in  males          40  mg/dl  (1  mmol/l)  or  more 
1.2  mmol/l  or  more  in  females 


Triglycerides  (fasting)      less  than  1.7  mmol/l 


less  than  200  mg/dl  (2.3  mmol, 


30 


Cholesterol 


Average  cholesterol  levels  in  women  aged  30  and  above 

mmol/litre 

estimated  to  2005 

#  data  from  urban  populations  only 


rf 
9 


Average  cholesterol  levels 

in  men  more  than  0.4  mmol/litre 

higher  than  in  women 


Average  cholesterol  levels 

in  women  more  than  0.4  mmol/litre 

higher  than  in  men 


6.0  and  above 
5.5-5.99 
5.0-5.49 
3.0-4.99 

no  data 


Fatty  deposits  along  the  inside 
of  artery  walls  lead  to 
atherosclerosis  and 
narrowing  of  the  arteries. 

Trends  in  cholesterol  levels  in  Beijing,  China 

Average  total  cholesterol  in  people  aged  25  to  64  years      5  25 

7984-7999 

mmol/l 

'1999 


1996 


1996 


1984 


1993 


31 


Risk  factor:  tobacco 


"From  a  short  pleasure  can  come  a  long 

repentance." 

French  proverb 


The  public  may  believe  that  the 
major  risk  from  cigarettes  is  lung 
cancer,  but  far  more  smokers 
develop  cardiovascular  disease  — 
mainly  heart  attacks  and  stroke.  In 
1940,  a  link  was  identified 
between  cigarette  use  and 
coronary  heart  disease,  and  there 
is  now  a  huge  body  of  scientific 
literature  linking  tobacco  with 
CVD.  The  risks  are  much  higher 
in  people  who  started  smoking 
before  the  age  of  16.  Tobacco 
use,  other  than  smoking,  and 
passive  smoking  are  also 
implicated  as  CVD  risks. 

Smoking  promotes  CVD 
through  several  mechanisms.  It 
damages  the  endothelium  lining 
of  the  blood  vessels,  increases 
cholesterol  plaques  (fatty  deposits 
in  the  arteries),  increases  clotting, 
raises  LDL-cholesterol  levels  and 
lowers  HDL,  and  promotes 
coronary  artery  spasm .  Nicotine 
accelerates  the  heart  rate  and 
raises  blood  pressure. 

A  gene  has  been  discovered  that 

o 

increases  smokers'  risk  of 
developing  coronary  heart  disease 
by  up  to  four  times.  Around  a 
quarter  of  the  population  carries 
one  or  more  copies  of  this  gene. 

Women  smokers  are  at 
particular  risk,  with  a  higher  risk 
of  heart  attack  than  male 
smokers.  Women  who  smoke 
only  three  to  five  cigarettes  a  day 
double  their  risk  of  heart  attack, 
while  men  who  smoke  six  to  nine 
cigarettes  a  day  double  their  risk. 


32 


Cardiovascular  risks  of  smoking 


Percentage  increase  in  risk 

100% 
increase  in  risk 


300% 

increase  in  risk 


more  than  300% 

increase  in  risk 


400% 

increase  in  risk 


stroke;  coronary 

heart  disease; 

impotence 


death  from 

undiagnosed 

coronary  heart 

disease 


Aim 

'' 


peripheral 
arterial 
disease 


aortic 
aneurysm 


Cardiovascular  risks  of  passive  smoking 


Adults 

Harms,  clogs,  and  weakens  arteries 
Heart  attack,  angina,  stroke 


Children 

•  Reduces  amount  of  oxygen  the  blood  can  carry 

•  Damages  arteries 

•  Earlv-onset  atherosclerosis 

•  Sudden  infant  death  svndrome  (cot  death) 


Smokers  don't  know  the  risks  of  heart  attack 


Percentage  of  smokers 
in  the  USA 

who  believe  they  have 
higher-than-average 
i/ftThf  heart  attack    -, 
1399 


39% 

heavy    Y4 
smokers 
(40  or 

more 
per  day) 


ft 


"S, 

1  <2»> 

*$* 


'*••'. 


DOMINICAN 

~^W~      r~* 

"'"T  VINCENT  E,    ^ST  LUCIA. 

GRENABI«S-«0  BARBADOS. 
COSTA  RICA      ,,* 
PANAMA* 


MAURITANIA       **Al 
SENEG* 


KIIAIKM 


UWJGUAv 


Men 


Smoking  prevalence 

Percentage  of  people  aged  18  years  and  above 

who  smoke 

2003  or  latest  available  data 

*  data  from  urban  populations  only 

IB    6Qo/o  and  above 
B    45o/o-59.9% 
300/0-44.9% 


—  LATVIA 
—  LITHUANIA 
-BELARUS 
Y  POLAND 


•  JAMAICA     "*'"     «EP 
EMALA  STVINCENTE,      ^  LUCIA. 

GRENADINES^  O  B^BOS, 

COST*RI" VtNBUBA. 


CAMBODIA  PHIUPP.NB 


URUd 
AB6ENTINA 


Women 


8 


"Take  a  stroll  after  meals  and  you  won't 

have  to  go  to  the  medicine  shop." 

Ancient  Chinese  proverb 

Industrialization,  urbanization  and 
mechanized  transport  have 
reduced  physical  activity,  even  in 
developing  countries,  so  that 
currently  more  than  60%  of  the 
global  population  are  not 
sufficiently  active. 

Physical  exercise  is  linked  to 
longevity,  independently  of 
genetic  factors.  Physical  activity, 
even  at  an  older  age.  can 

O      ' 

significantly  reduce  the  risk  of 
coronary  heart  disease,  diabetes, 
high  blood  pressure,  and  obesity, 
help  reduce  stress,  anxiety  and 
depression,  and  improve  lipid 
profile.  It  also  reduces  the  risks  of 
colon  cancer,  breast  cancer  and 
ischaemic  stroke. 

Doing  more  than  1 50  minutes 
of  moderate  physical  activity  or 
60  minutes  of  vigorous  physical 
activity  a  week  —  whether  at 
work,  in  the  home,  or  elsewhere 
—  can  reduce  the  risk  of  coronary 
heart  disease  by  approximately 
30%. 

Despite  documented  evidence 
of  the  benefit  of  physical  activity 
in  preventing  and  treating 
cardiovascular  and  other  chronic 
diseases,  more  than  a  quarter  of  a 
million  individuals  die  each  year 
in  the  United  States  because  of  a 
"lack  of  regular  physical  exercise". 

Only  8%  of  the  world's 
population  currently  owns  a  car. 
Between  1980  and  1998,  the 
global  fleet  of  cars,  trucks  and 
buses  grew  by  80%,  with  a  third 
of  the  increase  taking  place  in 
developing  countries. 


34 


Risk  factor: 
physical  inactivity 


Sitting 

Time  spent  seated  each  week, 

people  aged  18  years  and  above 

2000 

selected  countries 


j/nours  35  hou| 

U^!S     29  hours       •  • 


Finland,          Italy      Netherlands     Spain        United 
France  Kingdom 


Physical  activity 

The  following  activities  have  similar  benefits  to  health: 

Washing  and  waxing  a  car  for  45-60  minutes 

Washing  windows  or  floors  for  45-60  minutes 

Playing  volleyball  for  45  minutes 

Wheeling  self  in  wheelchair  for  30-40  minutes 

Bicycling  8  km  in  30  minutes 

Pushing  a  pushchair  2.5  km  in  30  minutes 

Walking  3  km  in  30  minutes 

Swimming  laps  for  20  minutes 

Playing  basketball  for  15-20  minutes 


Physical  inactivity  by  social  class  in  India 

Percentage  of  time  spent  seated,  at  work  or  in  spare  time, 
by  people  aged  25  years  and  above  in  two  Indian  villages 
7993-7995 


82o/o 


69% 


27% 


D 


lowest 


6%     6% 

CDCD 

next  lowest      next  highest          highest 


37% 


r 


UNITED 
KINGDOM         omuHK 


INLAND 


SWEDEN 


^u. 


•JIIH 


GERMANY 


BELGIUM       - 

MflVAKiA 
LUXEMBOURG  ^^ 

FRANCE  ^«a 

CROATI 

ITAIY 
SPAIN 
ff^H 
PORTUGAL  GREECE 


BRAZIL 


Mf ^ 

URUGUAY  MM|^^B|j^HH|^H|^HHjj^^^^^«|^^HHHHBMB| 

Physical  activity  levels 

Energy  expenditure  per  week  in  work,  leisure  and  transport 

MET-mins 

2002-2003 

1  MET  is  the  amount  of  energy  expended  while  sitting  quietly  at  rest 

H    6000  and  above  below  1300  ^ 

HI    3500-5999  no  data 


Singapore  keeps  moving 

Percentage  participation  in  any  form  of  sport  for 

at  least  20  minutes,  on  3  or  more  days  a  week,  by  age 

1998 


750 


^y  female 

240/0 

9  male 

16% 

11  O/n 

^^^^ 

1  1    /U 

16% 

32% 

25% 

9%| 

24% 

=s 
14% 

1  6% 

Transport 

Number  of  motor  vehicles 

per  1000  people 

7996 

selected  countries 


The  global  fleet 

Number  of  vehicles      1000 
1950-1994,  million 

2025  projected 

630 

million 


97 


81 


8 


USA    Japan    Brazil    Hong     China    India 
Konq 


1950       1994       2025 


18-29    30-39    40-49    50-59    60-69 
years      years     years      years     years 


35 


"Eat  less  at  dinner  and  you  will  live  to 

ninety-nine." 

Ancient  Chinese  proverb 


Belt  size,  abdominal  girth  and 

O 

waist-to-hip  ratio  are  useful 
indicators  of  obesity.  The  Body 
Mass  Index  (BMI),  a  measure  of 
weight  in  relation  to  height,  is 
commonly  used  for  classifying 
overweight  and  obesity. 

The  risks  of  cardiovascular 
disease  and  type  2  diabetes  tend  to 
increase  on  a  continuum  with 
increasing  BMI,  but  for  practical 
purposes  a  person  with  a  BMI  of 
over  25  is  considered  overweight, 

o       ' 

while  someone  with  a  BMI  of  over 
30  is  obese.  But  one  size  does  not 
fit  all.  In  women,  a  BMI  as  low  as 
2 1  may  be  associated  with  the 
greatest  protection  from  coronary 
heart  disease  death.  The  BMI  for 
observed  risk  in  different  Asian 
populations  varies  from  22 
to  25  kg/m2. 

Availability  of  food,  changes  in 
the  kind  of  food  eaten,  and 
decreased  exercise  are  presenting 
humanity  with  one  of  its  greatest 
challenges.  Low  fruit  and 
vegetable  intake  accounts  for  about 
20%  of  CVD  worldwide.  Obese 
smokers  live  1 4  fewer  years  than 
nonsmokers  of  normal  weight. 

More  than  60%  of  adults  in  the 
USA  are  overweight  or  obese. 
Triple-width  coffins,  capable  of 
holding  a  300  kg  (700  Ib)  body,  are 
in  increasing  demand.  Worldwide, 
airlines  are  having  to  recalculate 

O 

their  passenger  "payload"  weight. 
There  are  70  million  overweight 
people  in  China.  South  Pacific 
populations  used  to  be  physically 
active  and  slim,  but  the  region  now 
has  some  of  the  world's  highest 
rates  of  obesity. 


Risk  factor:  obesity 


Food  consumption 

Trends  in  food  consumption  in 
developing  and  industrialized  countries 
7964-  7999,  2075  projected 
kcal  per  capita  per  day 


Industrialized  29_4Z 
countries 


Developing  2Q54 
countries      • 

1964-66 


1974-76 


1984-86 


1997-99 


2015 


"If  you  and  three 

friends  together 

weigh  more  than 

360kg,  you  get  a 

free  bottle  of 

whisky." 

Ichub  Club. 

fat-themed 

karaoke  bar  in 

Bangkok, 

Thailand, 

2002 


Apple  shape  at  higher  risk  of  CVD  than  pear  shape 

Waist-to-hip  ratio  of  0.91  and  above  is  associated  with  nearly 
threefold  increased  risk  of  coronary  heart  disease. 


Increased  CVD  risk  if:      Men 


Women 


Waist  to  hip  ratio 
Waist  measurement 

more  than  0.90 

more  than  101cm 
(40  inches) 

more  than  0.85 

more  than  89cm 
(35  inches) 

Cartoon  characters  used  to  promote  the 
WeightWise  campaign  of  the  British 
Dietetic  Association. 


36 


NIGERIA 
GHANA          .CAMEROON 


JAfAN 
REP 
KOREA 


COOK 
ISLANDS 

THAILAND  • 

PHILIPPINES 


N    D   0    N    E   S   I    A 


Men 

Body 

HiHHH 


MALAWI 
ZIMBABWE 


Mass  Index  (BMI) 


Average  BMI  of  people  aged  1 5  years  and  above 

estimated  to  2005 

kg/m2 

*  data  from  urban  populations  only 


18-22.9 
no  data 


Women 


10 


"The  urine  of  diabetics  is  wonderfully 

sweet  as  if  imbued  with  honey  or  sugar." 

Thomas  Willis  (1621-1675),  physician  to 

King  Charles  II,  England 

Diabetes  is  a  risk  factor  for 
coronary  heart  disease  and  stroke, 
and  is  the  most  common  cause  of 
amputation  that  is  not  the  result 
of  an  accident. 

Insulin  is  a  hormone  produced 
by  the  pancreas  and  used  by  the 
body  to  regulate  glucose  (sugar). 
Diabetes  occurs  when  the  body 
does  not  produce  enough  insulin, 
or  cannot  use  it  properly,  leading 
to  too  much  sugar  in  the  blood. 
Symptoms  include  thirst, 
excessive  urination,  tiredness,  and 
unexplained  weight  loss. 

There  are  two  main  types  of 
diabetes.  Type  1  diabetes,  in 
which  the  pancreas  stops  making 
insulin,  accounts  for  10%  to  15% 
of  cases.  The  majority  of  people 
with  diabetes  have  type  2  disease, 
in  which  insulin  is  produced  in 
smaller  amounts  than  needed,  or 
is  not  properly  effective.  This 
form  is  preventable,  because  it  is 
related  to  physical  inactivity, 
excess  calorie  intake  and  obesity. 
People  with  type  1  diabetes  need 
insulin  injections  to  lower  blood 
sugar,  but  many  people  with 
type  2  do  not. 

At  least  half  of  all  people  with 
diabetes  are  unaware  of  their 
condition.  Diabetes  is  more 
prevalent  in  developed  countries, 
but  modernization  and  lifestyle 
changes  are  likely  to  result  in  a 
future  epidemic  of  diabetes  in 
developing  countries. 


Risk  factor:  diabetes 


CANADA 


Lifestyle  changes  can  be 
more  effective  than  drugs 
in  preventing  type  2 
diabetes. 


GREENLAND 
(DK) 


DOMINICAN 


JAMAICA 
BELIZE 

GUATEMALA  HONDURAS 

EL  SALVADOR 


HAITI 

ST  Kins  Et  NEVIS  I 


NICARAGUA 
COSTA  RICA 


r-.  ANTIGUA  ft  BARBUDA 
O  DOMINICA 
ST  VINCENT  ft  GRENADINES  0O$T  LUCIA 

GRENADA  6      O BARBADOS 

^  TRINIDAD  Et  TOBAGO 
VENEZUELA 


GUYANA 


COLOMBIA 


CAPE  VERDE  O 

SENEGAL 

GAMBIA 

GUINEA-BISSAU 

GUI 

SIERRA  LEONE 


38 


Prevalence  of  diabetes 


D 

DM 

NETH 
BELGIUM 
I 

LATVIA 
DENMARK                      LITHUANIA 

BELARUS 
GERMANY               "OWN° 
"PUBLIC    SLOVAK,A    "*»** 

HI     10%-14.9% 
50/o-9.90/o 

Percentage  of  people  aged  20  and  above  Top  5 

with  diabetes  2000  largest  numbers 

^_  of  people  aged  20  and  above 

15%  and  above  below  5%  with  diabetes 

2000 
no  data 


RnMANIA 


. 

AUSTRIA     HUNGARY 
FRANCE      SWITZ.  SIOVENIA     BOSNIA  ft 

S  MARINO  HERZEGOVINA 

"CROATIA    '    SERBIA  &    BULGARIA 

-ORRA  MONACO        ITALY 


RUSSIAN     FEDERATION 


KAZAKHSTAN 


TURKEY  "\.  TURKMENISTAN 

Vlfcj  TAJIKISTAN 

"*  CYPRUS       SYRIAN  ARAB 

LEBANON-    "EPUBUC  ISL   REP'        AFGHANISTAN 

ISRAEL- 


LIBYAN 
ARAB 

JAMAHIRIYA 


EGYPT 


CHAD  SUDAN 


IRAQ  IRAN 


SAUDI  ARABIA 


PAKISTAN 


MONGOLIA 


C  H  I 


BANGLADESH 

MYANMAR 


ERITREA        YEMEN 

DJIBOUTI 
ETHIOPIA  ^ 


EQUATORIAL  CAMEROON 
GUINEA 


GABON 

DEM.  REP.  RWANDA 

CONGO  CONGO  BURUNDI 


UNITED  REP 
TANZANIA 

COMOROS 

MALAWI 
IBIA 

MADAGASCAR 
ZIMBABWE  MAURITIUS 


SOUTH 
AFRICA 


SWAZILAND 
LESOTHl 


Diabetes  prevalence  and  trends 

c 

8.4% 


Percentage  of  people  aged  20  and  above 
with  diabetes 


2000  2030 

developed  countries 


2000  2030 

developing  countries 

4444444-4-4 


4 \ +— 


39 


11 


"Wealth  is  both  an  enemy  and  a  friend." 
Nepalese  proverb 


In  developing  countries,  coronary 
heart  disease  has  historically  been 
more  common  in  the  more 
educated  and  higher 
socioeconomic  groups,  but  this  is 
beginning  to  change.  In  industrial 
countries,  such  as  Canada,  the 
United  Kingdom,  and  the  United 
States,  there  is  a  widening  social 
class  difference  in  the  opposite 
direction. 

Studies  in  developed  countries 
suggest  that  low  income  is 
associated  with  a  higher  incidence 

o 

of  coronary  heart  disease,  and 
with  higher  mortality  after  a  heart 
attack.  The  prevalence  of  risk 
factors  for  heart  disease,  such  as 
high  blood  pressure,  smoking  and 
diabetes,  is  also  higher.  The  use  of 
medications  is  lower,  especially  of 
lipid-lowering  agents  and  ACE 
inhibitors,  as  well  as  other 
treatments,  such  as  cardiac 
catheterization. 

The  pathways  by  which 
socioeconomic  status  might  affect 
cardiovascular  disease  include: 
lifestyle  and  behaviour  patterns; 
ease  of  access  to  health  care;  and 
chronic  stress. 


Risk  factor: 
socioeconomic  status 


Prevalence  of  CVD  risk  factors 
by  education  in  Canada 

Percentage  of  people  aged  1 8  to  74  years 
with  high  levels  of  physical  inactivity 
and  high  cholesterol,  by  educational  level, 
age  standardized  1986-1992 


men 

f  women 

physical  inactivity 

high  cholesterol 


secondary  school  not  complete' 
47% 
46% 

secondary  school  completed 
37% 


45% 


physical  inactivity 
high  cholesterol 

university  degree  obtained 
physical  inactivity  37% 

high  cholesterol 


38% 


The  CVD  mortality  gap  in  the  USA 


Percentage  increased  CVD  mortality 

of  lowest  socioeconomic  (SE)  group 

over  highest  SE  group, 

in  people  aged  25  to  64  years 

7969-7998 

49% 


94% 


79% 


30% 
1969-1970    1997-1998 


Prevalence  of  high  blood  pressure 
by  income  in  Trinidad  and  Tobago 


Percentage  of  women  aged  24  to  85  years  with  blood  pressure 

of  140/90  mmHg  or  above,  or  currently  treated 

2007 


1% 

•  III  ~ 


less  than 
US$134 


US$ 
134-267 


US$ 
268-533 


US$  US$        more  than 

534-1067    1068-2133     US$2133 


monthly  household  income 


I 


Educational  level  and 
obesity  in  Italy 


Percentage  increased  risk  of  obesity  in  people 

aged  35  to  74  years,  380% 

in  comparison 

with  university  graduates 

7998 


2200/0 


I 


250% 


upper 
secondary 
education   60% 
diploma 


no 
qualification 


In  China,  years  of  education  are  more  important  than  occupation,  income  or 
marital  status  in  relation  to  cardiovascular  risk  factors,  especially  cigarette 
smoking. 


Smoking  and  occupation  in  Uganda 


Percentage  of  women  aged  1 5  to  54  years  and  men  aged  1 5  to  59  years 

who  currently  smoke  daily  by  category  of  work 

2000-2007 


34% 


33% 


29% 


**  ^%  ^% 


14% 


10/Q 


0% 


3% 


agriculture,     unskilled 
self-employed    manual 


skilled 
manual 


*  Smo 


sales      professional,  unemployed 
technical,      (previous 
managerial,    12  months) 
clerical 


Smoking  by  years  of  education  in  South  Africa 


Percentage  of  people  aged  15  years  and  above  who  currently  smoke  daily 
7998 

;f    men 
r   women 


45o/o 


45o/o 


39% 


35% 


33% 


25o/o 


100/° 


jl 


8%  9%  8% 

no  up  to  6-7  8-11  12  more  than 

education      5  years  years  years  years  12  years 


Income  and  obesity  in  Saudi  Arabia 

Percentage  of  people  aged  20  years  and  above 
with  Body  Mass  Index 
of  more  than  30  kg/m2 
7990-7993 


income  less  than          US$  US$        more  than 

US$533      533-1066    1067-2133     US$2134 


Prevalence  of  diabetes 
by  income  in  India 


Percentage  of  people 
aged  20  years  and  above 
with  diabetes, 
by  income  level 
2000 


22% 


less  than 


more  than 


US$111      112-223      US$223 


41 


12 


Women:  a  special  case? 


Widespread  misconceptions 
persist  about  heart  disease,  often 
thought  to  be  primarily  a  disease 
of  middle-aged  men.  In  reality, 
cardiovascular  disease  affects  as 
many  women  as  men,  albeit  at  an 
older  age.  Many  women  still 
believe  that  they  are  more  at  risk 
from  cancer  than  from  heart 
disease. 

Risk  factors  for  CVD  are  similar 
for  men  and  women,  but  tobacco 
use  is  more  dangerous  in  women. 
In  addition,  high  blood 
triglycerides  are  an  important 
cause  of  atherosclerosis  in  young 
women,  but  not  in  young  men. 
The  menopause  has  no  direct 
effect,  but  hormone  replacement 
therapy  increases  the  risk  of 
CVD. 

Heart  disease  is  under-detected 
in  women,  particularly  younger 
women.  In  developed  countries, 
women  are  less  likely  to  be 
referred  to  a  heart  specialist,  to 
be  hospitalized,  to  be  prescribed 
medicine  or  invasive  treatment, 
or  to  be  referred  for  exercise 
testing  or  echocardiography. 
Women  are  more  likely  to  enter 
the  medical  system  with  the 
diagnosis  of  a  second  heart  attack. 

After  a  first  stroke,  women  are 
kept  in  hospital  longer,  and 
remain  more  disabled  than  men 
receiving  similar  care.  More 
research  is  needed  to  improve  our 
understanding  of  the  differences 
in  responses  to  treatment  in  men 
and  women. 

In  the  interim,  however, 
adherence  to  the  published 
guidelines  for  the  prevention  and 
control  of  heart  disease  and  stroke 
seems  prudent. 


42 


Risk  factors 

Modifiable  risks  -  risk  or  prevalence  is  higher  in  women  than  men 


Tobacco  use  (higher  risk) 
High  triglyceride  levels  (higher  risk) 
Diabetes  (more  prevalent) 
Obesity  (more  prevalent) 
Depression  (more  prevalent) 


Modifiable  risks  -  risk  is  similar  in  men  and  women 

•  High  blood  pressure 

•  High  total  cholesterol 

•  Low  HDL-cholesterol 

•  Combined  hyperlipidaemia 

•  Unhealthy  diet 

•  Physical  inactivity 

•  Stress 


Risks  for  women  only 

•  Oral  contraceptive  use 

•  Hormone  replacement  therapy 

•  Polycystic  ovary  syndrome 

•  Risk  of  heart  attack  highest  early  in  each  menstrual  cycle 


Non-modifiable  risks  for  men  and  women 

•  Advancing  age 

•  Gender 

•  Heredity 

•  Ethnicity/race 


Smoking 

Percentage  increase  in  risk  of  heart  attack 
in  people  who  smoke  in  Denmark 
7976-7993 


60% 


ex-smokers  light  smokers         moderate  smokers        heavy  smokers 

(1-Hg/day)  (15-24  g/day)  (>24g/day) 


Women  who  smoke  are  at 

higher  risk  of  heart  attack 

than  men  who  smoke. 


No  time  to  walk 

Percentage  of  women  in  the  United  Kingdom 
aged  15  years  and  above  who  do  not  exercise  more 
because  of  lack  of  time  or  motivation 
2003 
40% 


Walking  re 
coronary  heart  disease 

Percentage  reduction  in  risk  of 
coronary  heart  disease  by  non- 
vigorous  walking  in  women 
45  and  above  in  the  USA 
7992-7999 


Hormone 
replacement  therapy 

Percentage  increase 
in  risk  of  CVD 
in  healthy  women 
using  HRT  in  the  USA 
7997-2000 


41% 


111% 


29% 

lul 


no  time      not  motivated 
to  exercise      to  exercise 


1-59 
minutes 
a  week 


1-1.5  2  or  more 

hours  hours 

a  week  a  week 


22% 


coronary 

heart 

disease 


stroke 


deep 

venous 

thrombosis 


43 


PART  3 


THE  BURDEN 


"You  don't  get  to  choose  how  you're  going  to  die,  or  when. 
You  can  only  decide  how  you're  going  to  live  now." 

Joan  Baez,  folk  singer  and  activist,  USA  (1941-) 


45 


13 


"Misfortunes  always  come  in  by  a  door 

that  has  been  left  open  for  them." 

Czechoslovakian  proverb 


Disability-adjusted  life  years 
(DALYs)  lost  can  be  thought  of  as 
"healthy  years  of  life  lost".  They 
indicate  the  total  burden  of  a 
disease,  as  opposed  to  simply  the 
resulting  deaths. 

Cardiovascular  disease  is 
responsible  for  10%  of  DALYs 
lost  in  low-  and  middle-income 
countries,  and  18%  in  high- 

O 

income  countries. 

A  heart  attack  occurs  when  the 
blood  vessels  supplying  the  heart 
muscle  become  blocked,  starving 

O 

it  of  oxygen,  leading  to  the  heart 
muscle's  failure  or  death.  Heart 
attack  has  the  same  risk  factors  as 
CVD  in  general.  Cold  weather. 

O 

exercise,  or  strong  emotion  can 
precipitate  a  heart  attack. 

Coronary  heart  disease  is 
decreasing  in  many  developed 
countries,  but  is  increasing  in 
developing  and  transitional 
countries,  partly  as  a  result  of 
increasing  longevity, 
urbanization,  and  lifestyle 
changes. 

Risk  of  heart  attack  can 
change  when  people  migrate. 
Japan  has  a  low  rate  of 
coronary  heart  disease,  but 
after  moving  to  the  USA, 

O 

Japanese  people  have  been 
found  to  have  a  gradually 
increasing  risk.  This 

O 

eventually  approaches  that 
of  people  born  in  the  USA. 


Global  burden  of  coronary 
heart  disease 


Coronary  heart  disease  burden  is  projected  to 
rise  from  around  47  million  DALYs  globally  in 
1990  to  82  million  DALYs  in  2020. 


USA 


JAMAICA 
BELIZE 
HONDURAS 


REP 


ST  KITTS  ft  NEVIS  0O  ANTIGUA  ft  BARBUDA 


EL  SALVADOR 

NICARAGUA 


ST  VINCENT  ft  GRENADINES 


COSTA  RICA 

PANAMA 


6RENADA  .3       O  BARBADOS 

'-'  TRINIDAD  ft  TOBAGO 
VENEZUELA 

GUYANA 


GUINEA-BISSAU 

GUINI 
SIERRA  LEC 


46 


sase  burden  in  men 


Percentage  of  DALYs  lost 
due  to  top  ten  diseases 
n  men  aged  15  years  and  above 
2002 


HIV/AIDS    coronary 
7.4%  heart  disease 
6.8% 


chronic 
obstructive 
pulmonary    hearing 
disease         loss. 
3.1%         adult 
2.7% 


alcohol 

use 
disorders 


tuberculosis 
4.2% 


ElANP 


UNITtD 

KINGDOM 


MNLAND 
SWEDEN 
NORWAY 

ESTONIA 

LATVIA 

LITHUANIA 


DENMARK 


Healthy  years  of  life  lost  to  coronary  heart  disc 

DALYs  lost  per  1000  population,  age-standardized 
estimates  for  2002 

Disability-adjusted  life  years  combine  years  of  potential  life  lost  due 
to  premature  death  with  years  of  productive  life  lost  due  to  disability 


3      NIGERIA 
||| 

OIRt    *  2  CENTRAL  AFRICAN  • 

REPUBLIC 
EQUATORIAL  CAMEROON 

GUINEA  UGANDA 

GABON  KENYA 

^PRINC^E  DEM-REP.  RWANDA 

CONGO  BURUMO, 

UNITED  REP 
TANZANIA 


MALAWI 


ANGOLA 

ZAMBIA 

ZIMBABWE 

NAM'BIA    BOTSWANA 

MOZAMBIQUE 


COMOROS 


MAURITIUS 


SOUTH 

AFRICA       LESOTHO 


SWAZILAND 


AUSTRALIA 


unipolar 
depressive 
disorders 


HIV/AIDS 
7.2% 


-4-4 


coronary 
heart 
disease       stroke 

5.3%          5.2% 


Disease  burden  in  women 

Percentage  of  DALYs  lost  due  to  top  ten  diseases 
in  women  aged  15  years  and  above 
2002 


chronic 
obstructive 
cataracts    h"ring    pulmonary 

3'1%        ->8%       doS™C  tuberculosis  osteo-      diabetes 
1.8%        2.7%         26%       arthrit.s     mdijtus 


47 


14 


"People  live  with  their  own  idiosyncrasies 

and  die  of  their  own  illnesses." 

Vietnamese  proverb 


Civilization  kills.  Since  1990, 
more  people  have  died  from 
coronary  heart  disease  than  from 
any  other  cause.  Unlike  stroke, 
coronary  heart  disease  is  a 
comparative  newcomer  on  the 
world  stage.  Variations  in  death 
rates  are  marked:  they  are  lower 
in  populations  with  short  life 
expectancy. 

Heart  disease  mortality  rates  are 
also  affected  by  differences 
between  countries  in  the  major 
risk  factors,  especially  blood 
pressure,  blood  cholesterol, 
smoking,  physical  activity  and 
diet.  While  genetic  factors  play  a 
part,  80%  to  90%  of  people  dying 
from  coronary  heart  disease  have 
one  or  more  major  risk  factors 
that  are  influenced  by  lifestyle. 

Death  rates  from  coronary  heart 
disease  have  decreased  in  North 
America  and  many  western 
European  countries.  This  decline 
has  been  due  to  improved 
prevention,  diagnosis,  and 
treatment,  in  particular  reduced 
cigarette  smoking  among  adults, 
and  lower  average  levels  of  blood 
pressure  and  blood  cholesterol.  It 
is  expected  that  82%  of  the  future 
increase  in  coronary  heart  disease 
mortality  will  occur  in  developing 
countries. 

Of  all  coronary  heart  disease 
patients  who  die  within  28  days 
after  the  onset  of  symptoms, 
about  two-thirds  die  before 
reaching  hospital.  This  highlights 
not  only  the  need  for  early 
recognition  of  the  warning  signs 
of  a  heart  attack,  but  also  the 
need  for  prevention. 

48 


Deaths  from  coronary 
heart  disease 


Despite  implements  in  survival 

1  in  4  men^Bi  1  in  3  women  still  die  withir 

of  a  recogn^B  first  heart  attack. 


Deaths  from 
coronary  heart  disease 
compared  with  other  causes 

Number  of  deaths  of  people 
aged  15  to  59  years, 
and  60  years  and  over 
2002 
thousands 


CAPE 

VERDE     MAfl 


GUINEA-BISSAUj 
OUINfl 


15-59  years 


60  years  and  above 


Deaths  from  coronary  heart  disease 


Number  of  deaths  from  coronary  heart  disease 
2002 


1000-9999  T°P 3 


highest  number  of 
deaths  from 
coronary  heart 
disease 


500  000  and  above 
100000-499999 
10  000-99  999 


-49% 


increase  in  death  rates 

Croatia 
Kazakhstan 
Belarus 
Ukraine 
Romania 
Japan  -10% 

Hungary  -2%  ||+2% 

-11% -15%    Greece 
-19%     l^HB^l  Portugal 
USA 

Netherlands 
-40%  -Mi  Sweden 

Luxembourg 
Australia 

Denmark 
decrease  in  death  rates 


Change  of  heart 

Percentage  change  in 

coronary  heart  disease  death  rates, 

in  people  aged  35  to  74  years 

7988-7998 

selected  countries 

women™ 
men 


49 


15 


"I  waked  and  sat  up.. .when  I  felt  a 

confusion  and  indistinctness  in  my  head 

which  lasted,  I  suppose  about  half  a 

minute.  Soon  after  I  perceived  that  I  had 

suffered  a  paralytick  stroke,  and  that  my 

Speech  was  taken  from  me." 

Samuel  Johnson,  England,  1783 


Stroke  is  the  brain  equivalent  of  a 
heart  attack.  Blood  must  flow  to 
and  through  the  brain  for  it  to 

o 

function.  If  its  flow  is  obstructed, 
by  a  blood  clot  moving  to  the 
brain,  or  by  narrowing  or  bursting 
of  blood  vessels,  the  brain  loses  its 
energy  supply,  causing  damage  to 
tissues  leading  to  stroke . 

Annually,  1 5  million  people 
worldwide  suffer  a  stroke.  Of 
these,  5  million  die  and  another 
5  million  are  left  permanently 
disabled,  placing  a  burden  on 
family  and  community.  Stroke  is 
uncommon  in  people  under 
40  years;  when  it  does  occur,  the 
main  cause  is  high  blood  pressure. 
Stroke  also  occurs  in  about  8%  of 
children  with  sickle  cell  disease. 

The  major  risk  factors  for  stroke 
are  similar  to  those  for  coronary 
heart  disease,  with  high  blood 
pressure  and  tobacco  use  the  most 
significant  modifiable  risks.  Atrial 
fibrillation,  heart  failure  and  heart 
attack  are  other  important  risk 
factors. 

The  incidence  of  stroke  is 
declining  in  many  developed 
countries,  largely  as  a  result  of 
better  control  of  high  blood 

o 

pressure,  and  reduced  levels  of 
smoking.  However,  the  absolute 

O 

number  of  strokes  continues  to 
increase  because  of  the  ageing 
population. 


Global  burden  of  stroke 


CANADA 


The  increased  risk  of  stroke  from  taking 
contraceptive  pills  is  substantially  reduced  by 
using  the  modern,  low-dose  pill. 


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Healthy  years  of  life  lost  to  strol 


DALYs  lost  per  1000  population,  age-standardized 

2002 

Disability-adjusted  life  years  combine  years  of  potential  life  lost  due 

to  premature  death  with  years  of  productive  life  lost  due  to  disability 


NETH. 
BELGIUM  GERMANY 


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Stroke  in  young  people 

Number  of  new  cases  of  stroke 
per  100  000  people  per  year 
selected  populations 
7986-7997 


10 


14 


AUSTRALIA 


26 


/    ?       ?      f    ?     / 


NEW 
ZEALAND 


age  17-49  years  15-44       15-44 
Israel  Italy         Italy 

Florence          North 


0-39        40-49 
Kuwait     Kuwait 


15-40  20-54  11-50 

Libyan     South  Africa      Spain 
Arab  Blacks 

Jamahiriya 

Benghazi 


Cantabria 


20-44    20-44  20-44 

USA     USA  USA 

Northern          Northern  Northern 

Manhattan  Manhattan  Manhattan 

Blacks  Hispanics  Whites 


51 


16 


Stroke  carries  a  high  risk  of  death. 

O 

Survivors  can  experience  loss  of 
vision  and /or  speech,  paralysis, 
and  confusion.  Historically  called 
"apoplexy",  "stroke"  is  so  called 
because  of  the  way  it  strikes 
people  down. 

Previous  stroke  significantly 
increases  risk  of  further  episodes. 
Certain  racial,  ethnic  and 
socioeconomic  groups  are  also  at 
greater  risk  of  stroke.  The  most 
important  modifiable  cause  of 
stroke  is  high  blood  pressure;  for 
every  ten  people  who  die  of 
stroke,  four  could  have  been 
saved  if  their  blood  pressure  had 
been  regulated.  Among  those 
aged  under  65,  two-fifths  of 
deaths  from  stroke  are  linked  to 
smoking.  Other  modifiable  risk 
factors  include  unhealthy  diet, 
high  salt  intake,  underlying  heart 
disease,  diabetes  and  high  blood 
lipids. 

The  risk  of  death  depends  on  the 
type  of  stroke.  Transient 
ischaemic  attack  or  TIA  —  where 
symptoms  resolve  in  less  than 
24  hours  —  has  the  best  outcome, 
followed  by  stroke  caused  by 
carotid  stenosis  (narrowing  of  the 

v  o 

artery  in  the  neck  that  supplies 
blood  to  the  brain).  Blockage  of 
an  artery  is  more  dangerous,  with 
rupture  of  a  cerebral  blood  vessel 
the  most  dangerous  of  all. 

Even  where  advanced 
technology  and  facilities  are 
available,  60%  of  those  who 
suffer  a  stroke  die  or  become 
dependent.  Given  these  dismal 
statistics  and  the  high  cost  of 
treatment  of  stroke,  high  priority 
should  be  accorded  to  preventive 
strategies. 


52 


Deaths  from  stroke 


Stroke  is  the  second  leading  cause  of  death 
above  the  age  of  60  years,  and  the  fifth  leadir 
cause  in  people  aged  15  to  59  years  old. 


... 


% 


DOMINICAN 

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CAPE  VERDE  e. 

GAMB 
GUINEA-BISSA 


SENM 


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SIERRA  LEO 


420% 


Predictors  of  death 
from  stroke  in  Italy 

Percentage  increased  risk  of  death  from  stroke 

in  people  aged  65  years  and  above 

2007 


140% 


84% 


83% 


60% 


38% 


previous     atrial         high       impaired    cigarette    coronary 
stroke  fibrillation    blood       glucose     smoking       heart 
pressure  tolerance  disease 

(systolic 
>163  mmHg) 


Number  of  deaths  from  stroke 
2002 


Top  3 

highest  number  of 
deaths  from  stroke 


200  000  and  above 
100000-199999 
10  000-99  999 


1000-9999 
below  1000 
no  data 


100/0 

stroke 

5.5  million 


27% 

other  causes 
15.6  million 


heart  disea 
7.2  milli 


Total 

deaths 

57  million 


12% 
cancer 
1  million 


respiratory 
infections 
3.7  million 
5% 

HIV/AIDS 
2.8  million 


Stroke  compared 

with  other  causes  of  death 

Percentages  and  numbers  of  deaths 
worldwide  from  stroke  and 
other  leading  causes 
2002 

malaria 
1.2  million 

3% 

tuberculosis 
1.6  million 

30/0 

diarrhoeal  diseases 
1.8  million 

40/0 

perinatal  causes 
2.5  million 


5% 

chronic  obstructive 

pulmonary  disease 

2.7  million 


53 


17 


Economic  costs 


"The  art  of  economics  consists  in  looking 

not  merely  at  the  immediate  but  at  the 

longer  effects  of  any  act  or  policy;  it 

consists  in  tracing  the  consequences  of 

that  policy  not  merely  for  one  group  but 

for  all  groups." 

Henry  Hazlitt,  USA  (1894-1993) 

The  costs  of  cardiovascular  disease 
are  diverse:  the  cost  to  the 
individual  and  to  the  family  of 
heath  care  and  time  off  work;  the 
cost  to  government  of  health  care; 
and  the  cost  to  the  country  of  lost 
productivity. 

We  attempt  here  to  quantify 
some  of  these  costs.  However, 
the  value  of  a  human  life  is 
beyond  our  analysis. 


Global  costs  of  smoking 


Health  care  costs  associated  with 
smoking-related  illnesses  result 
in  a  global  net  loss  of  US$200 
billion  per  year,  with  one  third  of 
those  losses  occurring  in 
developing  countries. 
Estimated  1994. 


USA,  Australia  and  Europe 


2002  reports  indicate  that  up  to 
10%  of  health  budgets  are  spent 
on  diabetes-related  illnesses. 


USA 


Latin  America  and  the  Caribbean 


Permanent  disabilities  resulting 
from  diabetes  cost  US$50  billion 
in  2000,  while  costs  associated 
with  insulin,  hospitalization, 
consultations  and  care  totalled 
US$10.6  billion. 


uiooai  COSTS  or  uiaoeies 

Between  4%  and  5%  of  health 
budgets  are  spent  on  diabetes- 
related  illnesses. 
WHO,  2003 


Price  of  weekly  dose  of  medication 

Expressed  in  kg  of  cheapest  crop  available  (yam,  rice  or  potato) 

2003 

selected  countries 

Mk  "*'  -"'' 

Simvastatin  63.0 

^P  Aspirin 

50.6 


50.6 


38.4 


33.6 


/    "If  just  10%  of  adults  began  walking 
regularly,  Americans  could  save  US$5.6 
billion  in  costs  related  to  heart  disease." 
-  President  George  W.  Bush,  2002. 

The  direct  costs  of  physical  inactivity 
accounted  for  an  estimated  US$24  billion 
in  health  care  costs  in  1995. 

I  Health  problems  related  to  obesity,  such 
as  heart  disease  and  type  2  diabetes, 
cost  the  USA  an  estimated 
US$177  billion  a  year. 

Cholesterol  reducers  were  the  top-sellinc 
medications  in  2003,  generating 
US$13.9  billion  in  sales. 

The  American  Heart  Association 
estimates  that  stroke  will  cost  a  total  of 
US$53.6  billion  in  2004.  Direct  costs  for 
medical  care  and  therapy  will  average 
US$33  billion  and  indirect  costs  from 
lost  productivity  will  be  US$20.6  billion. 

In  2001,  the  National  Stroke  Association 
estimated  that  the  average  cost  per 
patient  for  the  first  90  days  after  a 
stroke  was  US$15  000,  although  10%  of 
cases  cost  more  than  US$35  000. 


30.0 


25.7 


0.9 


Chile 


1.5 


4.0 


1.4 


13.9 


1.2 


0.5 


4.2 


0.2 


1.6 


China         Egypt       Georgia       Ghana      Indonesia    Pakistan    Sri  Lanka      Turkey 


54 


United  Kingdom 


stroke 


"The  direct  cost  of  obesity  to  the  National  Health 
Service  is  £0.5  billion  [about  US$0.9  billion]  per 
year,  while  the  indirect  cost  to  the  UK  economy  is 
at  least  £2  billion  [about  US$3.5  billion]." 
-  Liam  Donaldson,  Chief  Medical  Officer,  2003 

More  than  4%  of  National  Health  Service 
spending  was  on  stroke  services  in  2000. 


The  economics  of  CVD 

fctto    physical  exercise 

B    obesity  ^      CVD 

cholesterol  ^^™*     tobacco 


Global  costs  of  heart  disease  medication 


The  average  total  costs  of  care  per  patient 
for  six  months  following  a  stroke  were 
estimated  at  €16  000  in  2003. 

Stroke  was  estimated  to  be  responsible  for 
3%  of  total  health  care  costs  in  the 
Netherlands  in  1994,  and  7%  of  costs  for  the 
population  aged  75  and  over.  Stroke  ranked 
second  on  the  list  of  most  costly  diseases  for 
the  elderly,  after  dementia,  and  these  costs 
are  expected  to  increase  by  40%  by  2015. 


The  number  of  people  who  die  or  are  disabled 
by  coronary  heart  disease  and  stroke  could  be 
halved  with  wider  use  of  a  combination  of 
drugs  that  costs  just  US$1 4  a  year. 
WHO,  2002 


>mgapore 

/Average  hospital  costs  for  stroke  were 
reported  in  2000  as  US$5000  per 
patient.  Ward  charges  accounted  for 
38%,  radiology  15%,  doctors'  fees 
10%,  medications  8%,  therapy  7%. 


The  cost  of  risk  factors 

Cumulative  Medicare  costs  of  treatment  of  cardiovascular 
disease  in  people  aged  65  years  to  death,  in  the  USA 

Risk  factors:       US$38044  US$38059 

US$  high  blood  pressure, 

high  cholesterol, 
cigarette  smoking, 
US$18604  abnormal 

electrocardiograms, 

a  history  of 

diabetes  or 

previous  heart  attacks 


Lifetime  costs  of  coronary  heart  disc 


US$11  711 


men  women 

low  risk 
no  heart  disease  risk  factors 


men  women 

3  or  more 
risk  factors 


Germany 

7996 

US$ 


Total  direct  costs 

Including: 
primary  care, 
clinical  care, 
rehabilitation 


US$48 
billion 


US$26 
billion 


Expenditure  on  cardiovascular  medications 

Percentage  of  total  annual  drug  expenditure 

7989-7997 

OECD  countries 


Total  indirect  costs 

Lost  productivity 
caused  by: 
short-term  and 
long-term  disability, 
death 


Average  cost  per  case:  US$82  000 


55 


- 


56 


PART  4 


"Keeping  your  body  healthy  is  an  expression  of  gratitude  to  the 
whole  cosmos,  the  trees,  the  clouds,  everything." 

Most  Venerable  Thich  Nhat  Hanh,  Vietnamese  Buddhist  monk  (1926—) 

57 


18 


Research 


"Science  knows  no  country,  because 

knowledge  belongs  to  humanity,  and  is  the 

torch  that  illuminates  the  world." 

Louis  Pasteur,  France  (1822-1892) 


From  the  description  of  how  a 
heart  muscle  cell  contracts  to  the 
elucidation  of  the  human  genome, 

o 

scientific  advances  in  basic, 
clinical,  and  population  research 
in  cardiovascular  disease,  and 
their  global  impact,  have  been 
phenomenal.  New  and  improved 
treatments  have  become  possible, 
and  novel  markers  of  future  risk 
have  been  identified. 

Yet  several  key  challenges 
remain.  There  is  a  widespread 
lack  of  research  capacity, 
standardized  data,  communication 
networks,  and  human  and 
financial  resources,  especially  in 
developing  countries. 

The  MONICA  (Multinational 
MONItoring  of  trends  and 
determinants  in  CArdiovascular 
disease)  Project  involved  teams 
from  38  populations  in 
2 1  countries  from  the  mid- 1 980s 
to  the  mid-1990s,  the  largest  such 
collaboration  ever  undertaken.  It 
was  set  up  to  explain  the  diverse 
trends  in  cardiovascular  disease 
mortality  observed  from  the 
1970s  onwards.  The  project 
monitored  a  study  population  of 
10  million  men  and  women,  aged 
25  to  64  years. 

MONICA  was  important  in 
measuring  levels  and  trends  in 
cardiovascular  diseases  and  their 
risk  factors  in  different 
populations,  in  monitoring 
prevention  policies  in  different 
countries,  and  in  demonstrating 
the  importance  of  the  new  acute 
and  long-term  treatments  that 
were  being  introduced. 

58 


Regional  research 

Percentage  of  publications  on 

CVD  by  region 
countries        jndexed  in  Med|ine 
not  assigned 


developing 
countries  _ 

^m 

Eastern 
Europe 


BARBADOS 

• 

•  TRINIDAD 
h TOBAGO 


2007 


.** 


Clinical  trials 

Number  of  published  clinical  trials  on 
humans  in  any  language  in  the  National 
Library  of  Medicine's  PubMed 
2004 

1 83     Road  traffic  accidents 


6539 

HIV/AIDS 
Arthritis 
Stroke 

6687 
i 

6912 

9758 

Diabetes 

22468 

ped  market 
onomies  SENJ 

f  GAMBIA  8 

78% 


Pulmonary  diseases 


Cancer 
Coronary  heart  disease 


CVD  research  publications 

••••••^••••••^••••••i 

Number  of  publications  on  cardiovascular  disease  indexed  in  Medline 
7997-2007 


Top  three  countries 


Research  funding  by  the  National 


r™* 

Institute  of  Health  in  the  USA 

Spending  on  disease  research 

on/r: 


1 

Emerging 

^Stroke^^^ 
$330m 

Mental 
health 

$1762m 

Biodefense 
$1554m 

infectious     I 
diseases 

$1362m 

Drug  abuse 
$1023m 

Nutrition 
$1016m 

Diabetes 
$9  10m 

59 


19 


Organizations 


"Don't  agonize.  Organize." 

Florynce  Kennedy,  Lawyer,  and  Civil  and 

Womens'  Rights  Activist  (1916-2000) 

The  World  Health  Organization's 
Cardiovascular  Disease 
Programme  is  conducted  through 
its  Geneva  headquarters,  and 
regional  and  national  offices 
worldwide.  The  World  Heart 
Federation  helps  people  achieve  a 
longer,  better  life  through 
prevention  and  control  of  heart 
disease  and  stroke,  focusing  on 
low-  and  middle-income  countries. 

In  addition  to  the 
nongovernmental  organizations 
(NGOs)  highlighted  here,  there 
are  many  international  NGOs  - 
from  the  World  Medical 
Association  to  Consumers 
International  —  that  include 
cardiovascular  disease  control  as 
part  of  their  activities. 

Only  international  and  regional 
organizations  are  shown  here. 
Not  mentioned  are  the  many 
national  organizations,  whose 
impact  may  extend  outside  their 
own  country,  such  as  the  Centers 
for  Disease  Control  and 
Prevention  in  the  USA,  the 
British  Heart  Foundation,  and 
ThaiHealth  in  Thailand.  Other 
national  NGOs  also  work  part 
time  on  CVD  issues. 

There  are  numerous  other 
partners  in  a  vast  arena  of  varied 
but  related  interests,  including 
organizations  involved  with 
women,  youth,  law,  economics, 
human  rights,  religion  and 
development. 

The  capacity  of  virtually  all 
cardiovascular  disease  control 
organizations  is  inadequate  to 
meet  the  challenge  of  the  CVD 
epidemic. 

60 


World  Health  Organization 
headquarters,  Geneva 


Mexico 


InterAmerican 
Society  of  Cardiology 


USA 


WHO  RO  Americas/Pan  American  Health  Organizatic 

CardioStart  International  Inc. 

Cardiothoracic  Surgery  Network 

Children's  HeartLink 

Congenital  Heart  Information  Network 

Gift  of  Life  International  Inc. 

HeartGift  Foundation 

Heart-to-Heart  International 

Heart-to-Heart  Int.  Children's  Medical  Alliance 

International  Children's  Heart  Foundation 

International  Children's  Heart  Fund 

International  Hospital  for  Children  (IHC) 

International  Stroke  Society 

Loma  Linda  University  Overseas  Heart  Surgery  Team 

Save  A  Child's  Heart  Foundation 

World  Heart  Foundation 

Heart  of  the  Americas 

InterAmerican  Heart  Foundation 


World  Conferences  on  Cardiovascular 


World  Congresses  of  Cardiology 


1st  1974  Buenos  Aires,  Argentina 

2"(l  1978  Tokvo,  japan 

V'(1  1982  MOM  <m  ,  Russian  Federation 

4th  1986  Washington,  DC,  USA 

5''1  1990  Manila,  Philippines 

6th  19^4  Berlin,  (ii-i-mam 

7th  1998  Rio  do  Janeiro,  Brazil 

8th  2002  Svdnov,  Australia 

l"1'  2006  Barcelona,  Spain 


International  Conferences  on 
Preventive  Cardiology 

l»t  1985  Mosom,  USSR 

2nd  1989  Washington,  DC,  USA 

3"!  1993  Oslo,  Nor\\a\ 

4th  1997  Montreal,  Canada 

5th  2001  Osaka,  Japan 

6th  2005  Iguassu,  Bra/il 


United  Kingdom 


World  Federation  of  Neurology 
European  Heart  Institute 


Belgium 


European  Heart  Network 


CVD  organizations 

WHO,  Headquarters  (HQ)  and  regional  offices  (RO) 
International  CVD  organizations 
Regional  CVD  organizations 


Denmark 

Austria 

WHO  RO  Europe 

Furnnpan  A<;«;nriatinn  for 

Switzerland 


WHOHQ 

Coeurs  pour  Tous  (Hearts  for  All) 

World  Heart  Federation 


•ranee 


European  Society 
)f  Cardiology 


Egypt 


WHO  RO  Eastern  Med. 


Nigeria 


African  Heart  Network 


Congo 


WHO  RO  Africa 


China 


International  Chinese 
Heart  Health  Network 


Pakistan 


Asia  Pacific  Society 
of  Cardiology 


India 


WHO  RO  South-East  Asia 
Initiative  for  Cardiovascular 
Health  Research 
in  Developing  Countries 


Philippines 


WHO  RO  Western  Pacific 
Asian  Pacific  Heart  Network 


'an  African  Society 
)f  Cardiology 


World  Stroke  Congresses 


!•>'  1989  '  Kyoto,  Japan 

2nd  1992  Washington,  IK  ,  USA 

3ri1  1996  Munich,  Germany 

4th  2000  Melbourne,  Australia 

5th  2004  Vancouver,  Canada 


International  Heart  Health 
Conferences 


2n(l 

3r(l 

4th 

th 


1995 
1998 

2001 
2004 


Victoria,  British  Columbia,  Canada 

Barcelona,  Spain 
Singapore 
Osaka,  Japan 
Milan,  Italv 


61 


20 


"No  matter  how  far  you  have  gone 

on  the  wrong  road,  turn  back." 

Turkish  proverb 

Good  control  of  blood  pressure, 
blood  cholesterol  and  blood  sugar 
levels,  and  other  cardiovascular 
risk  factors  is  the  key  to  reducing 
risks  of  heart  disease  and  stroke. 

Personal  behaviour  and  lifestyle 
choices  can  make  a  big  difference 
to  the  risk  of  coronary  heart 
disease  and  stroke.  It  is  estimated 
that  having  a  high-risk  lifestyle 
may  account  for  82%  of  coronary 
events  in  women.  Here,  we 
identify  personal  choices  that  can 
lower  individual  risk  for  heart 
disease  and  stroke.  The  choices 
apply  to  young  people  and  adults 
alike. 


Prevention:  personal  choices 
and  actions 


Personal  choices  in  lifestyles  and  behaviour 

1  Take  moderate  physical  activity  for  a  total 
of  30  minutes  on  most  days  of  the  week. 

2  Avoid  tobacco  use  and  exposure  to 
environmental  smoke;  make  plans  to  quit  if 
you  already  smoke. 

3  Choose  a  diet  rich  in  fruits,  vegetables  and 
potassium,  and  avoid  saturated  fats  and 
calorie-dense  meals. 

4  Maintain  a  normal  body  weight;  if  you 
are  overweight,  lose  weight  by 
increasing  physical  activity  and 
reducing  calorie  intake. 

5  Reduce  stress  at  home  and  at  work. 


Personal  actions  for  safeguarding  cardiovascular  health       Young  people 


1  Discuss  all  questions  with  your  health  care  provider. 

2  Have  regular  check-ups  from  your  health  care  provider. 

3  Have  your  blood  pressure  and  levels  of  blood  sugar  and 
cholesterol  checked.  -^ 

4  Follow  your  health  care  provider's 
instructions  regarding  physical 
activity,  nutrition,  weight 
management,  and  any  medications 
you  have  been  prescribed. 

5  Know  the  signs  and  symptoms 
of  heart  attack  and  stroke  and 
remember  that  both  conditions 
are  medical  emergencies. 

6  Know  your  blood  pressure  and 
cholesterol  level,  and  keep  them 
at  the  recommended  levels 
through  lifestyle  changes  and 
by  taking  any  prescribed 
medication. 

7  Lower  your  total  fat  and 
saturated  fat  intake  in 
accordance  with  your  health 
care  provider's  instructions. 

62 


1    Actions  and  choices  for  children  and 
adolescents  with  cardiovascular  disease,  or 
risk  factors,  should  be  discussed  with  a 
paediatrician  or  health  care  provider. 

Choose  a  diet  containing  a  variety  of  fruits, 
vegetables,  whole  grains,  dairy  products,  fish 
legumes,  poultry,  and  lean  meat. 

There  is  no  need  to  restrict  fat  intake  in 
children  under  two  years  of  age. 

4    For  children  over 
two  years  and 
adolescents, 
limit  foods  high 
in  saturated  fats 
(to  less  than 
10%  of  daily 
calorie  intake), 
cholesterol  (to  less 
than  300  mg  per 
day),  and 
trans-fatty  acids. 

Increase  physical  activity,  and 
avoid  tobacco  use  or  exposure  to 
environmental  tobacco  smoke. 


Eat  fruit  and  cereals 

Percentage  reduction  in  risk 

with  each  daily  increment  of  10  g  of  dietary  fibre 

reported  2004 

all  coronary  events 
^P  coronary  deaths          _7(y 


intzke 


30% 


14% 


Fibre  intake 


25% 


10% 


16% 


total  dietary  fibre 


cereal 


fruit 


The  benefits  of  stopping  smoking 

Time  since  last  cigarette        Effect 

20  minutes 

1  day 

3  months 

1  year 

5  to  1 5  years  later 

1 5  years  later 


Blood  pressure  and  pulse  rate  drop  to  normal. 

Probability  of  heart  attack  begins  to  decrease. 

Circulation  improves. 

Excess  risk  of  coronary  heart  disease  is  half  that  of  a  continuing  smoker. 

Risk  of  stroke  is  reduced  to  that  of  people  who  have  never  smoked. 


Risk  of  coronary  heart  disease  is  similar  to  that  of  people  who  have 
never  smoked,  and  the  overall  risk  of  death  almost  the  same,  especially 
if  the  smoker  quits  before  illness  develops. 


63 


21 


"Thinking  well  is  wise;  planning  well, 

wiser;  doing  well  wisest  and  best  of  all." 

Old  Iranian  proverb 


Significant  health  gains  in 
cardiovascular  health  can  be  made 
within  short  time  spans,  through 
public  health  and  treatment 
interventions  that  have  an  impact 
on  large  segments  of  the 
population. 

As  shown  here,  there  is  a  gap 
between  what  is  known  and  what 
is  done  in  practice,  for  both 
prevention  and  treatment  of 
cardiovascular  disease. 

Governments  are  stewards  of 
health  resources,  and  have  a 
fundamental  responsibility  to 
protect  the  health  of  citizens. 
Ministries  of  Health  and  the 
health  profession  can  play  various 
roles  in  reducing  CVD,  by 
making  data  available,  educating 
the  public,  making  treatments 
affordable  and  available,  advising 
patients  on  healthy  living 
practices,  and  advocating  for 
policy  and  environmental  change. 
These  have  been  the  essential 
messages  of  the  International 
Heart  Health  Conferences  and  the 
related  declarations  on  heart 
health. 


UK  dieticians  promote  the  benefits 
for  heart  health  of  eating  oily  fish, 
more  fruit  and  vegetables,  and  less 
saturated  fat. 

64 


Prevention:  population 
and  systems  approaches 

Noncommunicable  disease  (NCD)  prevention  and  control 

Percentage  of  countries  with  integration  of  components 

of  NCD  prevention  and  control  programmes  in  primary  health  care 

2007 

WHO  regions  940/Q 

88%  880/0 


65% 


Africa 


Americas          Eastern 


Minca  Americas  tasicrn  Europe          South-East         Western 

Mediterranean  Asia  Pacific 


EASTERN 

MEDITERRANEAN  WESTERN 

PACIFIC 


Availability  of  equipment 

Percentage  availability  of  basic  equipment 
at  primary  health  care  level  for  diagnosis  and 
management  of  high  blood  pressure  and  diabetes 

2001  96% 

WHO  regions 

86% 
81% 


for  high  blood  pressure 
for  diabetes 


97% 


94% 


96% 


n 


Africa 


Americas         Eastern 

Mediterranean 


Europe 


South-East 
Asia 


Western 
Pacific 


Bh 

Medical  professionals 

Number  of  medical  professionals  working  in 

noncommunicable  disease  control 

per  100  000  population 

2007 

WHO  regions 


685 


cardiologists 

primary  health  care  physicians 

nurses 


56 


247 


0.4 
13 


I 


0.3 


Africa 


Americas         Eastern 

Mediterranean 


Europe 


South-East 
Asia 


Western 
Pacific 


Antihypertensive  drugs 

Percentage  of  countries  in  each  re 
are  available,  affordable  to  low  in 
or  manufactured  locally 
2007 
WHO  regions 

gion  where  drugs 
:ome  groups, 

r  30%  1 
890^ 

57% 
91o/o 

67% 

480/o 

45% 

9  locally 
manufactured 

9  affordable 

70/0 

p==5 

740/o 

640/o 

83% 

^7  available 

460/o 

88% 

920/o 

100% 

960/o 

70o/o 

M 

( 

71o/o 

I 

Western 
Pacific 

Africa 

Americas 

Eastern 
;diterranean 

Europe 

>outh-East 
Asia 

Use  of  medication 
in  stroke  and 
coronary  heart  disease 

Percentage  prescription  of 

aspirin  and  statins 

to  persons  with  established 

coronary  heart  disease 

and  post-stroke  in  the  WHO 

PREMISE  demonstration 

project 

2002 

selected  countries 

^  aspirin 
statins 


95% 


96% 


83% 


66% 


29% 


S 


90/0 


790/o    81o/o 


38% 


i 


31% 


28% 


i 


16% 


Brazil     Egypt    India  Indonesia  Iran,   Pakistan    Sri      Turkey  Russian  Tunisia 

Islamic  Lanka  Federation 

Republic  of 


. 


89% 


78% 


660/0 


38% 


j 


23% 


i 


78o/o 


28% 


I 


58% 


22 


Health  education 


"Education  is  the  most  powerful  weapon 

which  you  can  use  to  change  the  world." 

Nelson  Mandela,  South  Africa  (191 8-) 

For  successful  prevention  and 
control  of  the  cardiovascular 
disease  epidemic,  changes  to 
policy,  legislation  and  taxation  are 
not  enough.  These  interventions 
will  not  be  effective  if  there  is  no 
public  understanding,  support 
and  demand  for  them.  Some  areas 
lie  beyond  legislation  —  for 
example,  the  choice  of  food  for 
families,  the  amount  of  salt  added 
in  cooking,  whether  or  not  to 
smoke  —  and  here  health 
education  is  essential  to  promote 
healthy  choices. 

Schools  provide  an  ideal  venue 
for  health  education.  They  can 
teach  about  risk  factors,  refusal 
skills,  and  the  strategies  of  the 
tobacco  and  food  industries.  For 
example,  young  people  can 
analyse  how  tobacco  industry 
promotion  attempts  to 
manipulate  them  by  equating 
smoking  with  growing  up, 
freedom  and  being  cool. 

Increasing  knowledge,  and 

O  O      ' 

changing  beliefs,  attitudes  and 
intentions,  on  their  own  are  not 
enough  to  change  behaviour. 
School  programmes  must  also 
lead  by  example,  by  making 
healthy  food  available,  providing 
exercise  facilities,  prohibiting 
tobacco  use  at  all  school  facilities 
and  events,  and  helping  students 
and  staff  lose  weight  and  quit 
smoking.  Ideally,  these  activities 
should  be  part  of  a  coordinated 
school  health  programme, 
reinforced  by  community-wide 
efforts. 

The  WHO  Global  School 
Health  Initiative  is  designed  to 
strengthen  international,  national 

66 


World  Heart  Federation  event 


participating  countries 
and  territories  2003 


The  Victoria  Declaration 
on  Heart  Health 


Heart  Health  Declarations 


See  Milestones  pp76-81 
for  further  details 


The  Victoria  Declaration 
on  Women,  Heart 
Disease  and  Stroke 


and  local  support  for  effective 
school  health  programmes  or 
"health-promoting  schools". 
Guidelines  have  been  developed 
on  various  factors  that  affect 
health,  such  as  tobacco,  diet  and 
physical  activity. 

The  WHO  Global  School-based 
Student  Health  Survey  is  aimed  at 
adolescents  aged  13  to  15  years, 
and  covers  nine  risk  or  protective 
factors.  Survey  results  will 
provide  information  on  trends 
over  time,  which  is  useful  for 
formulation  of  risk  reduction 
policies. 

World  Heart  Day  Themes 

•  2000  Physical  Activity 

•  2001  A  Heart  for  Life 

•  2002  Nutrition  and  Physical 
Activity 


World  Heart  Day  Activities  200? 

medical  activities 
(e.g.  blood  pressure    ] 
testing) 


2003  Women,  Heart 
Disease  and  Stroke 

2004  Children, 
Adolescents  and 
Heart  Disease 

2005  Obesity  / 


activities  to 
engage  the  public  in 

physical  activity    I  f 


scientific  activities 

(e.g.  conferences 

or  workshops) 


activities 
to  advocate  for  a 
heart  healthy  diet 

other  activities 

(e.g.  charity 

gala,  dance, 

concert,  carnival) 


The  Catalonia  Declaration 
Investing  in  Heart  Health 


The  Osaka  Declaration:  Health, 
Economics  and  Political  Action 
Stemming  the  Global  Tide 
of  Cardiovascular  Disease 


The  Milan  Declaration: 
Positioning  Technology  to 
Serve  Global  Heart  Health 


998  Singapore 


The  Singapore  Declaration: 
Forging  the  Will  for  Heart 
Health  in  the  Next  Millennium 


valuation  of  World  Heart  Days  2000-2003 
Number  of  participating  countries  and  territories 


till 

2000  2001  2002  2003 


Giving  up  smoking:  International  Quit  and  Win 

1994-2002, 2004  projected 

Up  to  25%  of  participants  in  the  International 

Quit  and  Win  Campaign  are  off  tobacco  after  one  year 


1  000000 


Number  of  participants 


Number  of 

website  hits        more  than 
2  000  000 


200  000 


60  000       70000 


420  000 


2000 


2002 


1998 


1994 


1996 


2000 


2001 


2002 


2003 


Number  of  countries      48 

€ 

1998 


67 


23 


Policies  and  legislation 


"The  welfare  of  the  people 

is  the  ultimate  law." 

So/us  Populi  Supreme  Est  Lex. 

Cicero  (1 06  BCE-43  BCE) 


Laws,  treaties,  policies  and 
regulations  have  played  important 
roles  in  the  prevention  and 
control  of  disease.  Only 
governments  can  legislate  for 
health  warnings  on  cigarettes, 
introduce  mandatory  food 
standards  and  labelling,  crack 
down  on  smuggling,  set  a  "pro- 
health  tax  policy",  or  implement 
national  transport  policy.  Often 
governments  are  the  main 
providers  of  health  care;  they 
decide  how  funding  is  allocated, 
from  prevention  programmes  to 
treatment,  research,  and  training. 

The  first  international 
convention  that  relates  specifically 
to  cardiovascular  disease  is  the 
WHO  Framework  Convention  on 
Tobacco  Control.  It  was  adopted 
without  dissent  by  the  World 
Health  Assembly  in  Geneva  in 
May  2003,  and  is  currently  in  the 
process  of  ratification.  Once 
40  countries  have  ratified  the 
Convention,  it  will  come  into 
effect  as  a  legally  binding  treaty 
among  those  countries.  The 

O 

Convention  includes  clauses  on 
advertising  bans,  smoke-free 
areas,  health  warnings,  taxation, 
smoking  cessation  and  smuggling. 


Cardiovascular  disease  plans 
worldwide 

Percentage  of  countries  by  region 

with  national  plans  for  CVD  prevention  and  control 

2007 

WHO  regions 

Africa  8% 


Americas 
Eastern  Mediterranean 


South-East  Asia 
Western  Pacific 


50°/o 


4QQ/0 


Smoke-free  workplaces 

Smoke-free  areas  in  government  buildings 

2004  or  latest  available  data 

r^    Smoking  in  private  workplaces  banned. 

•  Exceptions  or  limited  restrictions  may 

smoking  banned 
apply  to  restaurants,  bars, 

and  other  venues. 


First  five  countries  to  ratify 
the  Framework  Convention  on 
Tobacco  Control. 


smoking  restricted 
not  regulated 
unknown 


1970  Singapore:  smoking  banned  in  buses, 
cinemas,  theatres  and  other  specified 
buildings. 


Legislation 

Percentage  of  countries  by  region 

with  tobacco,  and  food  and  nutrition  legislation 

2007 

WHO  regions 


^  tobacco 
?  food  and  nutrition 


Africa  Americas          Eastern  Europe         South-East        Western 

Mediterranean  Asia  Pacific 


69 


24 


Treatment 


"If  you  do  not  repair  your  gutter,  you  will 

have  your  whole  house  to  repair." 

Old  Spanish  proverb 

In  1931,  Paul  Dudley  White 
noted  that  there  was  no  specific 
treatment  for  coronary  heart 
disease.  He  described  the 
treatment  of  high  blood  pressure 
as  "difficult  and  almost  hopeless". 
Today,  effective  and  relatively 
inexpensive  medication  is 
available  to  treat  nearly  all 
cardiovascular  diseases,  including 
high  blood  pressure. 

Improvements  in  surgical 
techniques  have  led  to  safer 
operations.  Effective  devices  have 
been  developed,  such  as 
pacemakers,  prosthetic  valves, 
and  patches  for  closing  holes  in 
the  heart.  Other  developments 
have  led  to  a  wide  array  of 
interventions  that  often  make 


surgerv  unnecessar 


7- 
Together,  these  advances  in 

o 

treatment  improve  quality  of  life 
and  reduce  premature  death  and 
disability.  They  also  add  to  the 
rising  costs  of  health  care. 
Increasingly,  high-technology 
procedures  are  chosen  over  less 
expensive,  but  nevertheless 
effective,  strategies. 

In  addition,  marked  disparities 
in  the  quality  of  treatment  can  be 
seen  in  groups  of  different  race, 
ethnicity,  sex,  and  socioeconomic 
status.  In  essence,  many  patients 
who  could  benefit  from  treatment 
remain  untreated,  or  inadequately 
treated.  In  future,  increased 
emphasis  needs  to  be  placed  on 
the  appropriate  use  of  proven 
treatments  for  everyone  with 
coronary  heart  disease  or  stroke. 


70 


Cardiac  rehabilitation 

Percentage  of  people  with  established 

coronary  heart  disease  advised 

to  participate  in  cardiac  rehabilitation 

2007 

selected  European  countries 


71% 


Patients  reaching  blood  pressure  and 
blood  cholesterol  goals  during  treatment 

Percentage  of  people  aged  70  years  or  below  with  established  CVD  who  achieve  blood  pressure 

goal  of  less  than  140/90  mmHg,  or  blood  cholesterol  goal  of  less  than  5.0  mmol/l 

2007 

selected  European  countries 

^  blood  cholesterol  goal  achieved 


46% 
50% 


23% 


55% 


63<>/o 


Types  of  treatment 

Selected  medication,  devices  and  operations 

Medication  used  in  treatment  of 

1  High  blood  pressure 

2  Coronary  heart  disease 

3  Heart  failure 

4  Arrhythmia  (heart  rhythm  disorders) 

5  Blood  clotting  disorders 
Devices 

1  Pacemakers 

2  Implantable  defibrillators 

3  Coronary  stents 

4  Prosthetic  valves 

5  Artificial  heart 
Operations 

1  Coronary  artery  bypass 

2  Balloon  angioplasty 

3  Valve  repair  and  replacement 

4  Heart  transplantation 

5  Artificial  heart  operations 

Trends  in  cardiovascular  operations  and 
in  the  USA 

Number  of  operations  and  procedures 

7987-2007 

thousands 

*  heart  catheterization 
^  open  heart  surgery 

'••    coronary  artery  bypass  surgery 
f  carotid  endarterectomy 

*  cardiac  pacemakers 


ACE 

inhibitors 


aspirin 


Simple  secondary 
25%  prevention 

medication  treatments 

Percentage  reduction  in 
250/0  two-year  risk  of  heart  attack, 
stroke  or  death  from  CVD 
in  patients  with  previous 
coronary  heart  disease 
or  stroke 
2002 


card 


Diabetes  treatment 

Percentage  of  persons  with  diabetes 

being  treated  with  medication  or  special  diet 

2002-2003 

selected  countries 


1981 


1986 


1991 


1996 


2001 


71 


*• 

s 


PART  5 


THE  FUTURE  AND  THE  PAST 


"Let  my  heart  be  wise, 
It  is  the  gods'  best  gift." 

Euripides  Medea,  431  BCE 


73 


25 


The  future 


"I  never  think  of  the  future  -  it  comes 

soon  enough." 

Albert  Einstein  (1879-1 955) 

I  Inlike  I  instein,  \\e  have  ID  iliink 
ol  the  lui  m  .  .   HI-    |)l.in  n.  P\\  ,  to 
reduce  (In-  numbers  ol deaths 
I'roin  coronary  heart  disease  .mil 
stroke. 

Predictions  arc  by  dicir  nature 
.speculative.  Nevertheless,  tliis 
nun  li  is  certain:  the  gloh.il 
epidemic  of  cardiovascular  disi-asc 
is  nol  only  increasing,  hut  also 
shifting  from  developed  to 
developing  nations. 

Action  can  work.  There  are 
MMI  mily  ahout  800  million 
people1  with  high  hlood  pressure 
worldwide.  Studies  now  indicate 
that  in  North  America,  Western 
Kurope,  and  the  Asia  Pacific 
region,  each  10  mmllg  lowering 
ol  systolic   hlood  pressin  .    [| 
assoi  iated  with  a  decrease  in  risk 
ol  stroke  ol  approximately  one 
third,  in  people  aged  (•>()  to  7C) 
years.  (Jobally,  if  diastolie  blood 
pressure  (l)UI')  can  he  redu.  i  d  h\ 
2%,  and  by  7%  in  those  with  DBP 
over-  l)S  mmllg,  a  million  deaths  a 

yi  .n   li HI. n  \   heart  disease 

and  stroke  could  he  averted  hy 
2020  in  Asia  alone. 

No  matter  what  advances  there 
are  in  high  technology 
medicine,  the  rundameiit.il 
message  is  that  am  major 
reduction  in  deaths  and 
disability  I'rom  ('VI )  will 
i  Mini    liom  prevention, 
not  i  ure.    This  must 
involve  robust  reduction 
of  risk  (actors. 


"Unless  current  trends  are  halted  or  reversed, 
over  a  billion  people  will  die  from 
cardiovascular  disease  in  the  first  half  of  the 
21st  century.  The  large  majority  will  be  in 
developing  countries  and  much  of  the  life  years 
will  be  lost  in  middle  age.  This  would  be  an 
enormous  tragedy,  given  that  research  in  the 
last  half  of  the  20th  century  showed  that 
cardiovascular  disease  was  largely  preventable." 

Anthony  Rodgers,  Clinical  Trials  Research  Unit, 
University  of  Auckland,  New  Zealand,  2004 


DALYs 

DALYs 

by  2010 

Disability-adjusted 
life  years  combine 

yi-ur,  nl  piilfiilinl 

life  lost  due  to 

CVD  DALYs 

Annual  number 
of  DALYs 

153  million 

premature  death 

w 

with  years  of 

V 

productive  life  lost 

Burden  of  CVD 

due  to  disability. 

Percentage 

10.4% 

of  all  DALYs 

m* 

by  2020 


169  million 


11.( 


by  2030 
187  million 


11.6% 


CVD 

rankings 
globally 

CVD  rankings 

in  developing 

countries 


DEATHS 

CVD  deaths 

Annual  number  of  deaths 


CVD  deaths 

Percentage 
of  all  deaths 

Coronary  heart 
disease  deaths 

Percentage  of 
all  male  deaths 

Coronary  heart 
disease  deaths 

Percentage  of 
all  female  deaths 

Stroke  deaths 

Percentage  of 
all  male  deaths 

Stroke  deaths 
Percentage  of 
all  female  deaths 

CVD  deaths 
from  cigarette 
smoking 

Annual  number  of  deaths 


3rd:  coronary 

he.irl  disease 
Mh  stroke 

4th  rtirnti.iry 

heart  disease 
8th:  stroke 


3rd:  coronary  3rd:  coronary 

hi-,-iri  diMMM'  heart  disease 

4th:  stroke  4th:  stroke 

3rd:  coronary  3rd:  coronary 

hr;iti  disease  heart  disease 

6th:  stroke  5th:  stroke 


by  2010  by  2020  by  2030 

24.2  million 


18.1  million 


30.8% 


13.1% 


13.6% 


9.2% 


20.5  million 


31.50/0 


1  4.3% 


1  3.0% 


9.8% 


11.  !•%  11.5% 

¥ 


3  2.  !>% 


14.9% 


13.1% 
10.4% 

11.8% 


2.6  million 


l-'l  m m 


74 


RISK 
FACTORS 

by  2010                     by  2020 

by  2030 

THfATMiNT          1,, 

by  2020                          by  2030 

Smokers 

1.4-1.  6  billion 
1.3-1.4  billion 

1.4-1.8  billion 

Miscellaneous       lull  |irr.nrul 

meili<  .il 

Health  systems  driven    Patients' 
by  primary  health  care    knowledge  of  their 

Number 

AA                •—  -»—  *  *^Bw* 

records 

to  ensure  universal        own  health  equals 

V 

stored  on 

access  to  quality           that  of  doctors  in 

MM.  Ill    1  .11(1 

health  care  services,       the  1990s. 

Diabetes 

366  million 

Number  of 

300  million 

Irr.l.mtancOUl 

people  aged 
20  years 

221  million 

computer  language 

iMM-.l.ltlllfl  rtl.llill", 

and  above 

^P 

ii.iiimi-,  in  he- 

understood  by  doctors 

Miscellaneous 

Serious  increases 

Short-term,  long- 

in  any  country. 

in  LDL-cholesterol 

term,  and  lifetime 

in  many 

absolute  risk  of 

Investigation     ECOs,  X-rays, 

Minuscule  computer,      "Trial  and  error"  In 

developing 

coronary  heart 

ultrasound 

with  microsensors,         drug  prescription 

populations. 

disease  and  stroke 

Images,  etc. 

automatically  sensing    abandoned  In 

routinely 

Ir.msmittnl 

and  recording  health      favour  of 

calculated  by 

electronically 

d.it.i,  (i)iil(l  hr  rvrryil.iy  |iOMin.ili/ril 

health  care 

t()lll.l(|MI>Ml< 

wear.                          prescription 

providers  for 

through 

everyone. 

in  another 

Biochemical                 pharmacogenomlc 

country. 

inflammation  and          testing  for 

genetic  markers  used     predictable 

Wireless  ECGs. 

routinely  in  blood  tests  responses  to  drugs. 

to  screen  patients  for 

ECONOMIC 
COSTS 

by  20  10                   by  2020 

by  2030 

heart  problems. 

Obesity-related 

'"*' 

complications 
Percentage  of 

70% 

Genetics     CVD- 
modifying 

Genetic  manipulation 
to  prevent  and  treat 

health  care 
spending  in  the 
USA,  people  aged 

15% 
W 

gcna 

identified. 

CVD,  including  post- 
operative prevention  of 
re-stenosis  of  arteries. 

50  to  69  years 

W 

ACTION       by  2010  by  2020  by  2030 

Research     New  causal     All  newborn  babies  Bio- 

and     factors  discharged  home  with  engineered 

development     discovered       CD-ROM  containing  their  tissues 

for  heart         unique  genomic  maps,  with  available  for 

disease,          summaries  of  CVD,  of  which  all  heart  and 

including        they  may  be  at  increased  vascular 

bacteria  structures, 
and  viruses. 

External  glucose  sensor  will 
drive  insulin  pumps  to 
deliver  continuous 
microdoses  of  insulin. 

Vaccine  produced  to  switch 
off  nicotine  receptors. 

Convention  on  Food  ratified  Convention 

(covering  content,  labelling,  on  universal 

taxation,  advertising).  access  to 
essential 

Millennium  Development  preventive 

Goals  (201 5):  access  to  health  care, 

affordable  essential  drugs  in  and 

developing  countries  principles  of 

provided,  in  cooperation  equity  in 

with  pharmaceutical  quality  care 

companies.  delivery. 


UN   WHO 

Conventions   Framework 
and  Goals   Convention 
on  Tobacco 
Control  (FCTO 
ratified. 

WHO  Global 
Strategy  on 
Chronic 
Diseases, 
Diet  and 
Physical 
Inactivity 
(2004). 


Artificial     Heart 
body  parts 
developed 


Transplant 
surgery 


High 
technology 


Medication 


luni)'.  lir.im.idil  orr. 

Nerves  to 
transplanted 

hr.irf. 

Xenotransplantatlon  Pig-napping  of 

with  pig  hearts  soars  personal 

as  rejection  problem  transgenic  pigs  a 

overcome.  new  crime. 


Nano-surgeons,  or  sub- 
microscopic  robots,  will 
crawl  through  arteries, 
scraping  away  fatty 
deposits  and  repairing 
damaged  or  diseased 
parts. 

Angiogenesis,  the 
growth  of  new  blood 

/rv.rl-.,  m.if  l.r.  ,,,,<r 

an  alternative  to 
coronary  bypass, 
angioplasty  or  clot- 
buster  drugs. 


Computerized 
"auto-doc" 
machine  externally 
detects  and  treats 
illness  by  magnetic 

Off-pump  beating 

hr,,rl   -..H'l'T/ 

predominates. 

Automated 
external 
defibrillators 
offered  as  f- . 
electronic  options 
in  new  homes  for 
persons  at  high 

M'>    .,1    VJ'I'I'T 

death, 


Six-drug  "polypill"  will 
reduce  CVD  by  more 
than  80%  if  taken  by 
everyone  aged  55  and 
older,  and  everyone 
with  existing  CVD, 


Drugs  developed 
to  raise  HDL- 


effective  as 
statins  are  today 
for  lowering  LDL- 
cholesterol), 


75 


TJ  /"^T"1 

- 

1  QC1 

A>I  *  1           .*-                         '1                        1J                     Cf 

[3  v^  l-^1 

- 

L03Z 

Milestones  in  knowledge  ol 

i          .        -|              "ii*    ^^  i 

lit 

— I 


Palaeolithic  era  Spain  Oldest 
anatomical  drawing  in  El  Pindal 

o 

cave  of  a  mammoth  with  a  dark 
smudge  at  the  shoulder,  which  is 
thought  to  represent  the  heart. 


2698-2598  BCE  China  Huang  Ti, 
the  Yellow  Emperor,  was 
thousands  of  years  ahead  of  his 
time  in  writing  in  Nei  Ching 
(Canon  of  Medicine):  "The  blood 
current  flows  continuously  in  a 
circle  without  a  beginning  or  end 

O  O 

and  never  stops"  and  "all  the  blood 
is  under  control  of  the  heart".  He 
also  recorded  the  association 
between  salt  intake  and  a 
"hardened  pulse". 

1550  BCE  Egypt  Papyrus  Ebers 
stated  that  after  death  the  heart 
becomes  the  witness  of  the  body's 
behaviour  during  life.  To  avoid 
incriminating  testimony,  the 
Egyptians  buried  the  heart 
separately  from  the  body. 


_L  _i- 
600  BCE  Greece  Alcmaeon  noted 

empty  arteries  in  animals  after 
death  and  inferred  that  arteries 
normally  contained  air. 

400  BCE  Gree, 
Hippocrates, 
the  Father  of 
Medicine 
(460-370  BCE), 
challenged  the 
belief  that 
illness  was 
caused  by  the 
^   gods;  he 

o 

believed  illness  was  caused  by  an 
imbalance  of  the  four  bodily 
humours:  yellow  bile,  black  bile, 
blood,  and  phlegm.  He  was  also 
the  first  to  recognize  stroke. 

310-250  BCE  Egypt  Erasistratus 
described  the  heart,  veins,  arteries 
and  valves,  but  claimed  that 


arteries  contained  "pneuma"  (air  or 
spirit  or  soul),  which  was  replaced 
each  time  a  person  breathed;  when 

artery  was  cut,  blood  rushed  in 

the  pneuma  escaped. 

&    131-201  CE 

Graeco-Roman 
physician 
Claudius  Galen, 
with  knowledge 
gained  from 
animals  killed 
by  Roman 
gladiators, 


described  the  heart  and  the 
movement  of  blood  in  the  arteries, 
but  claimed  that  the  liver  was  the 
ntre  of  the  circulation  and  that 
the  blood  passed  from  the  right  to 
the  left  side  of  the  heart. 

980-1037  Persia  Avicenna 

(Ibn  Sina)  stated  that  the  heart  is 

located  centrally  to  all  organs  of 

J  O 

the  body,  and  that  the  left  side  of 
the  heart  was  created  as  a  store  of 
spirit  and  soul. 


1210-1288  Syria  Ibn  al-Nafis 
described  the  pulmonary  and 
coronary  circulation  in 
he  Perfect  Man. 

1452-1519  Italy  Leonardo  da  Vinci 
incorrectly  drew  the  liver  as  the 
centre  of  circulation.  But  he  stated 
"vessels  in  the  elderly  through  the 
thickening  of  the  tunics,  restrict 
the  transit  of  the  blood."  This  is 
one  of  the  earliest  descriptions  of 
arteriosclerosis. 


1553  Spain  Michael  Servetus 
described  the  pulmonary 
circulation  in  his  book 
Christianismi  Restitutio. 


1510-1559  Padua,  Italy  Matteo 
Realdo  Colombo  described  the 
heart  valves. 


1525-1603  Rome,  Italy  Andrea 
Cesalpino  noted  that  the 
circulation  system  is  a  closed 
system,  and  was  the  first  in 
modern  times  to  coin  the  term 
"blood  circulation". 

1553-1 61 9 /Wua,  Italy 
Hieronymus  Fabricius 
demonstrated  valves  in  veins, 
which  help  to  "prevent  dilatation 
of  veins". 


15 55  Padua, 
Italy  Andreas 
Vesalius 
(1514-1564) 
stated  that  the 
heart,  and  not 
the  liver,  was 
the  centre  of  the 
circulation. 


1 559  Italy  Riva  di  Trento 
discovered  that  there  are  two 
coronary  arteries,  each  supplying 
blood  to  half  of  the  heart. 

1628  England  William  Harvey 
(1578-1657),  a  physician, 
published  his  thesis  that  the  heart 
pumped  blood  around  the  body, 
in  De  Motu  Cordis. 

mid- 1600s  Switzerland 
Jacob  Wepfer  found  that  patients 
who  died  with  "apoplexy"  had 
bleeding  in  the  brain.  He  also 
discovered  that  a  blockage  in  one 
of  the  brain's  blood  vessels  could 
cause  apoplexy. 

1 706  France  Anatomy  professor 
Raymond  de  Vieussens  first 
described  the  structure  of  the 
heart's  chambers  and  vessels. 

1712-1 780  England  John  Fothergill 
both  forecast  the  role  of 
psychosocial  factors  and  advised 


that  a  restricted  diet  "might  greatly 
retard  the  progress"  of  coronary 
heart  disease. 

1677-1761  England  Stephen  Hales, 
an  English  clergyman  and  scientist, 
first  measured  blood  pressure  In 
inserting  a  brass  tube  into  the 
artery  of  a  horse.  This  was  a 
scientific  experiment,  published  in 
1733,  demonstrating  that  the  heart 
exerts  pressure  in  order  to  pump 
blood.  The  horse  died. 

1745-1827  Italy  Alessandro  Volta 
discovered  that  electric  energy  was 
produced  by  heart  muscle 
contractions. 

1 749-1 832  England  Edward 
Jenncr,  better  know  for  smallpox 
vaccine,  made  the  essential  link 
between  angina  pectoris  and 
disease  of  the  coronary  arteries. 

1752-1832  Italy  Antonio  Scarpa 
described  arterial  aneurvsm. 

1772  England 
William  Heberden 
(1710-1801) 
described  angina 
pectoris:  "they  who 
are  afflicted  with  it, 
are  sei/ed  while 
thev  are  walking  (especially  if  it  be 
uphill,  and  soon  after  eating)  with  a 
painful  and  most  disagreeable 
sensation  in  the  breast,  which  seems 
as  if  it  would  extinguish  life  if  it 
were  to  increase  or  to  continue;  but 
the  moment  they  stand  still,  all  this 
uneasiness  vanishes".  He  was  also 
the  first  to  write  about 
byperlipidaemia  as  a  risk  factor 
when  he  noticed  that  the  serum  of 
an  obese  patient  who  suddenly  died 
was  "thick  like  cream". 


1775  Scotland  John  Hunter  (1728 
1793),  a  surgical  pathologist, 
wrote  "in  a  sudden  and  violent 
transport  of  anger,  he  fell  down 
and  expired  immediately", 
illustrating  the  importance  of 


emotion,  stress  and  anger  in 
precipitating  coronary  death. 
Hunter  himself  suffered  from 
angina  pectoris  and  died  suddenly 
alter  a  violent  argument  with  a 
hospital  colleague. 

1785  England  William  Withering 
described  the  use  of  digitalis  in 
coronary  heart  disease  in  his 
monograph  An  Account  of  the 
Foxglove.  Foxglove  had  been  used 
tor  centuries  bv  American  Indians. 


1791  Italy 
Luigi  Galvani 
discovered  that 
electrical 


L 


stimulation  of  a 
frog's  heart  led  to 
contraction  of  the 
cardiac  muscle. 


1799  England  Caleb  Hillier  found 
something  hard  and  gritty  in  the 
coronary  arteries  during  an 
autopsy  and  "well  remembered 
looking  up  to  the  ceiling,  which 
was  old  and  crumbling,  conceivii 
that  some  plaster  had  fallen  down". 
He  discovered,  however,  that  the 
vessels  had  hardened,  and  stated 
that  "a  principle  cause  of  the 
syncope  anginosa  is  to  be  looked 
for  in  disordered  coronary 
arteries". 

1815  England  London  surgeon 
Joseph  Hodgson  claimed 
inflammation  was  the  underlying 
cause  of  atherosclerosis  and  it  was 
not  a  natural  degenerative  part  of 
the  ageing  process. 

1815  France  M.E.  Chevreul  name 
the  fatty  substance  extracted  from 
gallstones  "cholesterol"  from  the 

O 

Greek  "khole"  (bile)  and  "stereos" 
(solid). 


symptoms  as  he  was  reluctant  to 
apply  his  ear  to  the  chest. 


1838  France  Louis  Rene  Lecanu 
showed  that  cholesterol  was 
present  in  human  blood. 

1841  Austria  Carl  Von  Rokitansky 
championed  the  thrombogenic 
theory,  proposing  that  deposits 
observed  in  the  inner  layer  of  the 
arterial  wall  derived  primarily 
from  fibrin  and  other  blood 
elements  rather  than  being  the 
result  of  a  purulent  process.  This 
theory  came  under  attack  from 
Rudolf  Virchow. 


— f-t- 


H 

1843  J.  Vogel  showed  that 
cholesterol  was  present  in 
atherosclerotic  plaques. 


1 844  Denmark 
First  pathology 
report  of  plaque 
rupture  in  a 
coronary  artery 
in  Bertel 
Thorvaldsen, 
the  celebrated 
neoclassical 

Danish  artist  and  sculptor,  who 
died  of  sudden  cardiac  death  in  the 
Royal  Theatre  in  Copenhagen. 

1 850  Ventricular  fibrillation  first 
described. 

1850s  Ophthalmoscope  invented, 
allowing  direct  visualization  of 

O 

arteries  at  the  back  of  the  eye. 

1852  England  Fatty  material  in  the 
coronary  arteries  described  by  Sir 
Richard  Quain,  which  he 
attributed  to  nutrition.  He  linked 
the  fatty  heart  to  "languid  and 
feeble  circulation,  a  sense  of 
uneasiness  and  oppression  in  the 
chest,  embarrassment  and  distress 


1819  France  Rene  Theophile 
Laennec  (1781-1826),  invented 
the  stethoscope.  He  rolled  paper 
into  a  cylinder  while  examining  a 
young  woman  with  cardiac 

J           o 

f 

in  breathing,  coma,  syncope, 
angina  pectoris,  sudden  death.  .  ." 

onzjq^ 

77 

1856  Germany 
Rudolf  Virchow, 
a  Pole,  believed 
that  disease 
occurred  at 
cellular  level, 
and  also 
described 
cerebral  emboli 
causing  stroke.  Virchow  also 
emphasized  the  societal  causes  of 
disease  as  "disturbances  of  human 
culture". 


1867  England  Lauder  Brunton, 
pharmacologist,  discovered  that 
amyl  nitrite  relieved  angina. 

lIIlXEtCEII 

1 872  France  Gabriel  Lippmann 
invented  the  capillary 
electrometer,  the  precursor  of  the 
electrocardiograph . 


: 


advertisements  said  that  the  drug 

o 

did  "not  affect  the  heart". 


1906  Germany  M.  Cremer,  first 
oesophageal  ECG  by  a  professiona 
sword  swallower.  First  fetal  ECG 
from  the  abdominal  surface  of  a 
pregnant  woman. 

1 907  England  First  case  report  of 
atrial  fibrillation  by  Arthur  Cushnv 
professor  of  pharmacology  at 
University  College,  London. 


1893  Holland  Willem  Einthoven 
(1 860-1927)  introduced  the  term 
electrocardiogram  or  ECG/EKG; 
distinguished  five  deflections  — 
PQRST  (1895);  constructed  the 
first  electrocardiograph  in  1901, 
which  weighed  270  kg,  occupi 
two  rooms  and  required  five 
people  to  operate  it;  transmitte 
the  first  ECG  from  hospital  to  his 
laboratory  1 . 5  km  away  via 
telephone  cable  (in  1905); 
published  the  first  normal  an< 
abnormal  ECGs  (1906)  and  won 
the  Nobel  Prize  (1924). 


1912  James  B.  Herrick  described 
heart  disease  resulting  from 
hardening  of  the  arteries. 


1912  First  human  cardiac 
catheterization  (no  X-ray 
visualization)  by  Frizt  Bleichroeder, 
E.  Linger  and  W.  Loeb. 

1915  USA  Establishment  of 
organization  in  New  York  City, 
which  became  the  American  Heart 
Association. 

920  USA  First  ECG  of  acute 


yocardial  infarction  by  Harold 


1 895  Germany  Physicist  Wilhem 
Konrad  Roentgen  (1845-1923) 


1923  USA  First  operative  widening 
of  scarred  cardiac  valve  by 
E.  Cutler  and  S.A.  Levine. 

^L  • 
1 925  United  Kingdom  Widening  of 

narrowed  mitral  valve  by  Souter, 
who  stretched  the  valve  ring  with 
his  fingers. 


disco\ 

ered  X-rays,  which  ar 
o  visualize  the  heart. 

T       : 

e  still 

„ 

' 

used  t 

— 

1896/ta/jScif 
invented  the  s 
to  measure  bl< 

1897  The  intr 
aspirin.  In  one 
ironies,  Bayer 

lione  Riva- 
jhygmoma 
)od  pressur 

aduction  o 
of  life's  lit 
s  first  aspii 

& 

10 

e. 

in 
tic- 
•in 

CCl 

m 
od 

tei 

en 

\ 

bl 

to 

ac 
V 

n 

hi 

1 

U! 

1928  United  Kingdom 

Sir  Alexander  Fleming  discovered 

O 

penicillin,  which  is  used  to  treat 
umatic  fever. 


Apoplexy"  divided  into 
tegories  based  on  the  cause  of  the 
blood  vessel  problem,  and  replaced 
by  the  term  "cerebral  vascular 
accident  (CVA)". 

1 929  Germany  First  documented 
right  heart  catheterization  in 


1931  USA  First  description  of  the 
use  of  exercise  to  provoke  attacks 
of  angina  pectoris  by  Charles 
Wolferth  and  Francis  Wood. 


1931  USA 

First  artificial 

cardiac 

pacemaker, 

which 

stimulated 

the  heart  by 

transthoracic 

needle, 

developed 


bv  Dr  Albert  Hvman. 


1937  USA  First  prototype  heart- 
lung  machine  built  by  physician 
John  Heysham  Gibbon,  and  tested 
on  animals.  He  performed  the  first 
human  open  heart  operation  in 
1953  using  the  machine. 

1938  USA  First  human  heart 
surgery,  first  surgical  correction  o: 
a  congenital  heart  defect:  closure 

o 

of  patent  ductus  arteriosus 
performed  by  surgeon 
Robert  E.  Gross. 

1944  China  First  repair  of  patent 
ductus  arteriosus  in  China. 

1 944  USA  First  operation  on  "blue 
baby"  (Fallot's  tetralogy)  at  Johns 
Hopkins. 


human  by  Werner  Forssmann 
using  radiographic  techniques. 


1944  USA  /Sweden  First  repair  of 
coarctation  of  aorta  by  Crafoord 
and  Grosse. 


1947  USA  First 
defibrillation 
of  human  heart 
during  cardiac 

O 

surgery,  by 
Claude  Beck  in 
Cleveland. 


1948  USA  "Blind  finger"  closed 
heart  surgery  for  mitral  stenosis 
reintroduced  by  Dr  Dwight 
Harken  and  Dr  Charles  Bailey. 


1948  USA  California  physician 
I  a\\ rrnce  Craven  noticed  that  400 
of  his  male  patients  who  took 
aspirin  tor  two  years  had  no  heart 
attacks.  By  1956,  he  had 
chronicled  the  health  of  8000 
patients  taking  aspirin  and  found 
no  heart  attacks  in  the  group. 

1948  USA  Start  of  the  Framingham 
Heart  Study  where,  for  the  first 
time,  a  large  cohort  of  healthy  men 
and  women  were  studied 
prospectively. 


1954  United  Kingdom  First  carotid 
endarterectomy  by  Eastcott, 
Pickering  and  Rob. 


1954  India  Called  on  WHO  to 
address  the  coming  epidemic  of 
cardiovascular  disease  in 
developing  countries. 


'55  United  Kingdom  First  reportec 


1949  USA  Portable  Holter  Monitor 
invented  bv  Norman  Jeff  Holter  to 
record  ambulatorv  ECG. 

1950  The  International  Society  of 
Cardiology  established,  later  joined 
with  International  Cardiology 
Federation  and  renamed  World 
Heart  Federation. 

1 950  Canada  First  pacemaker 
invented  by  John  Hopps. 

1952  USA  First  prosthetic  valve 
implanted  in  aorta  by  surgeon 
Charles  Hufnagel. 

1952  USA  First  successful  human 
open  heart  surgery  under 
hypothermia  bv  Walton  Lillehei 
and  John  Lewis,  who  implanted 
the  first  synthetic  valve  in  a 
live  year-old  girl  who  had  been 
born  with  an  atrioseptal  defect 
(hole  in  her  heart). 

1952  USA  External  cardiac 
pacemaker  designed  by  Paul  Zoll. 


itral  valve  replacement  by  Judson 
Chesterman. 

950s  Minimization  of  bias  for  the 

le  assessment  of 
cardiovascular  treatments  by 
introduction  of  randomization  into 
clinical  trials  (at  instigation  of  Sir 
Austin  Bradford  Hill). 


1960  USA  First 
replacement  of 
heart  valve  with 
Starr- Ed  wards 
mechanical  valve, 
developed  by 
Albert  Starr  (left) 
and  Lowell 
Edwards. 


1956  USA  First  report  of  the 
successful  ending  of  ventricular 
fibrillation  in  humans  by  externally 
applied  countershock  published  by 
Dr  Paul  Zoll. 


1957  First  battery-powered 


external  pacemaker. 


1 958  USA  Seymour  Furman 
inserted  a  pacemaker  in  a  patient 
lived  for  96  days. 


1958  Sweden  Internal  long-term 
cardiac  pacing  by  Ake  Senning. 


1953  USA  First 
demonstrated 


programme. 

•  •;"- 


coronary  artery 
disease  among 
young  US 
soldiers  killed  in 
action  in  Korea 
(later  observed  in 
the  casualties  of  the  Viet  Nam  Wa 
too)  by  William  F.  Enos,  Robert 


H.  Holmes  and  James  Beyer. 


1 958  Start  of  development  of  a 
selective  coronary  angiography 
procedure  by  Mason  Sones. 


1959  WHO  established 
Cardiovascular  Diseases 


1 960s  High  blood  pressure 
identified  as  a  treatable  risk  factor 
for  stroke . 


1960  USA  First  Coronary  Care 
Unit  in  Bethany,  Kansas. 

1960  Framingham,  USA  Cigarette 
smoking  found  to  increase  the  risk 
of  heart  disease. 


._ 


1961  USA  Framingham  Heart 
Study  investigators  coined  the  term 
"risk  factors"  for  the  development 
of  coronary  heart  disease.  High 
cholesterol  level,  blood  pressure, 
and  electrocardiogram 
abnormalities  found  to  increase  the 
risk  of  coronary  heart  disease. 

-j-4 

1961  USA  First  use  of  external 
cardiac  massage  to  restart  a  heart 
byJ.R.  Jude. 

1961  USA  First  direct  current 
dcfibrillation  with  external  paddle; 
by  Bernard  Lown  and  Barough 
Berkowitz. 


1960s  First  human  implant  of 
totally  implantable  pacemak 

1964  USA  First  transluminal 
angioplasty  performed  on  a 
narrowed  artery  in  the  leg  by- 
Charles  T.  Dotter. 


1965  USA  Michael  DeBakey  am 
Adrian  Kantrowitz  implanted 
mechanical  devices  to  help  a 
diseased  heart. 


1967  South  Ajrica  First  whole  heart 
transplant  from  one  person  to 
another  by  Dr  Christiaan  Barnard. 

1 967  USA  Saphenous  vein  coron 
bypass  graft  by  Dr  Rene  Favaloro. 

1967  Framingham,  USA  Physical 
inactivity  and  obesity  found  to 
increase  the  risk  of  heart  disease. 


1969  USA  First  use  of  artificial 
heart  in  human  by  Denton  Cooley. 

1972  USA  The  Stanford  Three 
Community  Study  started  (later 
becoming  The  Stanford  Five-City 
Project);  this  showed  a  23% 
reduction  in  coronary  heart  disease 
risk  caused  by  community-based 
interventions  that  change  lifestyle- 
related  risk  factors  such  as  physical 
activity,  dietary  habits  and  tobacco 


1972  Finland  North  Karelia  Project 
began,  aimed  at  preventing 
cardiovascular  disease  among 
residents.  Cardiovascular  mortality 
rates  for  men,  aged  between 
35  and  64  years,  decreased  by  57% 
from  1970  to  1992. 

1974  Framingham,  USA  Diabetes 
linked  to  cardiovascular  disease. 


1 970s  Aspirin  recognized  as 

preventing  heart  attacks  and 

i 

stroke. 


1970s  Development  of 
computerized  tomography  (CT)  to 
aid  early  diagnosis  of  stroke . 


1977 

Switzerland 

First  coronary 

PTCA 

(percutaneous 

transluminal 

coronary 

angioplasty); 

Andreas 

Gruentzif 

He- 
inserted  a  balloon-tipped  catheter 

into  a  coronary  artery  and  inflated 
the  balloon,  and  thus  successfully 
opened  a  blockage  and  restored 
blood  flow. 


1977  Italy  The  Martignacco  Project 
community  prevention  trial 


resulted  in  reduction  of  coronary 
heart  disease  through  community- 
>ased  interventions  that  change 
lifestyle-related  risk  factors  such  as 
physical  activity,  dietary  habits  and 
tobacco  use. 


1977  Framingham,  USA  Effects 
described  of  triglycerides  and  LDL- 
and  HDL-  cholesterol  on  heart 
disease. 


1978  Framingham,  USA 
Psvchosocial  factors  found  to  affect 
heart  disease. 


1978  Australia  North  Coast  Healthy 
Lifestyle  Programme  showed 

significant  reduction  in  smoking. 

5  & 

1978  Switzerland  Swiss  National 
Research  Programme  community 
prevention  trial  resulted  in 
reduction  of  smoking,  blood 
pressure  and  obesity. 

1978  Atrial  fibrillation  (irregular 
heart  beat)  found  to  increase  the 
risk  of  stroke . 

1979  South  Africa  Coronary  Risk 
Factor  Study  community 
prevention  trial  resulted  in 
reduction  of  smoking,  blood 
pressure  and  composite  coronary 
heart  disease  risks. 


1983  USA  List  of  246  coronary  risk 
factors  published  by  Hopkins  and 
Williams  (list  now  much  longer). 

1980s  Minimization  of  random 
error  for  the  reliable  assessment  of 
cardiovascular  treatments  by 
introduction  of  large-scale  "mega- 
trials"  (at  instigation  of  Sir  Richard 
Peto). 


1979  Germany  First  use  by  Peter 
Rentrop  of  intracoronary 
streptokinase,  a  clot-dissolving  drug 
to  stop  a  heart  attack  in  progress. 

1981  Framingham,  USA  Filter 
cigarettes  found  to  carry  as  much 
risk  for  coronary  heart  disease  as 
unfiltered  cigarettes. 


1981  USA  Report  on  relationship 
between  diet  and  heart  disease. 


1982  USA  First  permanent  artificial 
heart,  designed  by  Robert  Jarvik, 
and  implanted  by  Willem  DeVries, 
in  a  61  -year-old  man. 

* 


1 986  France  First  coronary  stent 
implanted  by  Jacques  Puel  and 
Ulrich  Sigwart. 

1987  Japan  M.  Okada  used  a  laser 
to  burn  channels  in  the  heart 
muscle  to  help  revascularize  the 
heart  in  patients  with  coronary 
heart  disease. 

1 987  Framingham,  USA  High  blood 
cholesterol  levels  found  to 
correlate  directly  with  risk  of  death 
in  young  men. 

J  O 

1988  Framingham,  USA  High  levels 
of  HDL-cholesterol  found  to 
reduce  risk  of  death. 


1988  ISIS- 2  trial 
shows 
emergency 
treatment  for 
heart  attacks 
with  aspirin  and 
fibrinolytic  "clot- 
busting"  drugs 
saves  lives. 


~~H^H 
1988  Framingham,  USA  Isolated 

systolic  hypertension  found  to 
increase  risk  of  heart  disease. 

1 988  Framingham,  USA  Cigarette 
smoking  found  to  increase  risk  of 
stroke. 


1990  Randomized  trials  showed 
that  lowering  blood  pressure 
lowers  the  risk  of  stroke. 

1990  United  Kingdom  Meta-analysis 
of  trials  by  Clinical  Trial  Service 
Unit  (CTSU)  in  Oxford  showed 


that  lowering  blood  pressure 
lowers  the  risk  of coronarv  disease. 

1991  China  Tianjin  CVD 
Intervention  Programme 
community  prevention  trial  led  to 
the  creation  of  non-smoking 

O 

environments  and  increased  sales 
ol  low-sodium  seasonings. 


Ilh/IIla  receptor  blockcr  drugs 
prevent  blood  clots;  the 
importance  of  inflammation  in 
cardiovascular  disease  recognized; 

O 

study  on  the  deadly  effects  of 
smoking  fewer  than  1 0  cigarettes 
per  day. 


re 


1 992  Canada  The  Victoria 
Declaration  on  Heart  Health 
affirmed  that  CVD  is  large  Iv 
preventable,  that  there  is  the 
scientific  knowledge  to  eliminate 
most  CVD,  and  that  the  public 
health  infrastructure  and  capacity 
to  address  prevention  were 
lacking. 

1990s  USA  Hostility  (including 
traits  such  as  anger,  cynicism,  and 
mistrust),  a  major  component  of 
type  A  behaviour,  shown  to  be 
associated  with  an  increased  risk  of 
heart  attack  and  other  cardiac 
complications  in  healthy  persons 
and  patients  with  coronary  heart 
disease. 

1992  China  First  heart-lung 
transplant  in  China. 


mid-1990s  Scandinavia,  United 
Kingdom,  USA  Remarkable 
improvement  in  survival  of 
coronary  heart  disease  patients 
treated  with  statins. 


1 998  Singapore  The  Singapo 
Declaration:  Forging  the  Will 

O        O 

Heart  Health  in  the  Next 
Millennium. 


2000  Canada  The 
Victoria 
Declaration  on 
Women,  Heart 
Disease  and 
Stroke  addressed 
the  importance  of 
science  and  polic 
in  action  and  the  need  to  tackle 
gender  disparities  in  health.  It 
called  upon  all  stakeholders  to  join 
forces  and  take  appropriate  actio 
to  control  the  cardiovascular 
disease  epidemic. 


1 995  Spain  The  Catalonia 
Declaration:  Investing  in  Heart 
Health,  and  its  follow-up 
convention  in  1997,  emphasized 
the  importance  of  investments  in 
heart  health  and  provided  examples 
of  many  successful  CVD  prevention 
programmes  worldwide. 


2000  First  World  HeartJOay,  whu 
has  become  a  global  annual  event. 

2000  The  entire  human  genome  is 
mapped. 

2000  WHO  53rd  World  Health 
Assembly  endorsed  Global  strateg' 
for  noncommunicable  disease 
(NCD)  prevention  and  control, 
which  outlines  major  objectives  for 
monitoring,  preventing  and 
managing  NCDs  with  special 
emphasis  on  major  NCDs  with 
common  risk  factors  and 
determinants  cardiovascular 
disease,  cancer,  diabetes  and 
chronic  respiratory  disease. 


Cardiovascular  Disease  emphasized 
the  global  nature  of  the  CVD 
burden  and  highlighted  the  need  to 
address  economic  and  political 
factors  in  order  to  tackle  CVD. 

2002  United  Kingdom  The  Heart 
Protection  Study  showed  that 
statins  could  benefit  people  with 
diabetes  and  those  with  cholesterol 


levels  previously  considered  low. 

1  J 

2002  USA 

NASA's 
Commercial 
Invention  of  the 
Year  Award 
given  for  the 
DeBakey 
Ventricular 
Assist  Device, 
based  on  space  shuttle  technology, 
and  developed  by  Michael 
DeBakey  (above)  and  NASA 
engineer  David  Saucier.  The 
pump,  used  to  treat  heart  failure, 
was  one-tenth  the  size  of  previous 
heart-assist  devices,  and  was  first 
used  in  a  patient  in  2000. 

2003  Switzerland  WHO 
Framework  Convention  on 
Tobacco  Control  adopted  at  the 

56th  World  Health  Assembly. 

J 


1998  USA  Hypertension  gene  in 
men  identified. 

1998  New  advances: 


gene  therapy  grows  new  blood 
vessels  to  the  heart;  strong 

confirmation  that  "superaspirin" 
1         * 


2001  Japan  The 
Osaka 

Declaration: 
Health, 
Economics  and 
Political  Action: 
Stemming  the 
Global  Tide  of 


2003  Switzerland  The  World 
Health  Report:  "Shaping  the 
Future"  highlighted  CVD  as  the 
first  of  three  growing  threats  that 

O  O 

make  up  the  "neglected  global 
epidemics".  The  report  called  for 
action  at  the  national  and  global 

O 

levels  to  prevent  and  control  CVD. 


2004  Switzerland  WHO  Global 
Strategy  on  Diet,  Physical 


Activity  and  Health  endorsed  by 
World  Health  Assembly. 

2004  Italy  Milan  Declaration  on 
Heart  Health:  Positioning 

O 

Technology  to  serve  Global  Heart 
Health. 


%'*• 

f 


PART  6 


WORLD  TABLES 


"Live  as  if  you  were  to  die  tomorrow.  Learn  as  if  you  were 
to  live  forever." 


Mahatma  Gandhi  (1869    1948) 


83 


World  Data  Table 


Country 

Afghanistan 

i 

Population 

Thousands 
2002 

22930 

2 
Heart  disc 
Disability 

DALYS  lost  |HT  1000 
population 
2002 
36 

ase 

3 
Stroke 

4 
Rheumatic 
heart  disease 

Number  of  deaths 

2002 

1  938 

Mortality 
Number 

ol  'deaths 
2002 
33  157 

Disability 

DAI.YS  lost  per  1000 
population 
2003  or  Idlest  iii(j//()/)/r  ,/,»,! 

13 

Mortality 
Number 

ol  deaths 
2002 
11  532 

Albania 

3  141                      13 

3989 

13 

4  169 

42 

Algeria 

31  266                       7 

14948 

8 

16223 

756 

Andorra 

69                       3 

67 

3                                  52 

3 

Angola 

13  184                     13 

7  130 

15                             7  640 

615 

Antigua  and  Barbuda 

73                       6 

52 

13 

92 

0 

Argentina 

37  981                       6 

34292 

6 

22  668 

234 

Armenia 

3072 

20 

8515 

10 

4212 

151 

Australia 

19544                       5                      25474 

3 

11  730 

243 

Austria 

8  111                       6                      15418 

4 

7  559 

185 

Azerbaijan 

8297 

28 

22302 

9 

6  540 

184 

Bahamas 

310                       5                           154                           6 

155 

1 

Bahrain 

709                       8                           283                           3 

84 

6 

Bangladesh 

143809                     18 

130006 

9 

64515 

10253 

Barbados 

269                       6 

286 

7 

270 

2 

Belarus 

9940                    28 

59  719 

14 

22  892 

550 

Belgium 

10296                      5 

14985 

4 

9  234 

68 

Belize 

251                       8 

153 

7 

111 

1 

Benin 

6  558                     10 

3017 

12 

3  279 

236 

Bhutan 

2  190                     20 

2672 

10 

1  370 

195 

Bolivia 

8645                      6 

3948 

7 

3  138 

70 

Bosnia  and  Herzegovina 

4  126 

10 

5590 

13 

6508 

21 

Botswana 

1  770                       8 

697 

8 

670 

15 

Brazil 

176257                       9 

139601 

11 

129  172 

3055 

Brunei  Darussalam 

350 

5 

92 

6 

90 

7 

Bulgaria 

7965                     14 

26243 

13 

20882 

232 

Burkina  Faso 

12624                     11 

5877 

13 

6604 

466 

Burundi 

6602 

10 

3084 

12 

3  492 

82 

Cambodia 

13810 

13 

7635 

11 

5963 

614 

Cameroon 

15729 

10 

9443 

12 

10  198 

621 

Canada 

31  271 

5 

43246 

3 

15621 

422 

Cape  Verde 

454 

6 

202 

Q 

266 

4 

Central  African  Rep. 

3  819 

10 

2  513 

12 

2  727 

51 

Chad 

8348 

10 

4385 

12 

4747 

300 

Chile 

15613 

4 

9075 

5 

8  142 

315 

China 

1  294  867 

4 

702  925 

12 

1  652  885 

97  245 

Colombia 

43  526 

8 

31  289 

6 

17  745 

380 

Comoros 

747 

8 

282 

10 

310 

23 

Congo 

3633 

9 

1  577 

10                             1  718 

39 

Congo,  Dem.  Rep. 

51  201                     11 

24217 

13 

26439 

1  930 

Cook  Islands 

18                    10 

11 

12 

11 

0 

Costa  Rica 

4094 

6 

2937 

3 

1  194 

45 

Cote  d'lvoire 

16365 

11 

9257 

12 

9530 

233 

Croatia 

4439 

10 

11  653 

11 

8653 

152 

Cuba 

11  271 

8 

16275 

5 

7  684 

196 

Cyprus 

796 

7 

1  358 

3 

795 

1 

Czech  Republic 

10246 

11 

25899 

7 

15663 

286 

Denmark 

5351 

5 

10013 

4 

4871 

17 

84 

imoking  prevalence 

Percentage  ol  people   1  N 
ears  and  above  who  smoke 
.W.J  or  latest  available  Jata 


46.2%  22.8% 

40.2%  11.5% 

49.6%  35.9% 


32.0% 
67.4% 
30.706 
37.4% 
32.0% 

29.5% 
63.0% 
19.8% 
63.60/0 
33.2o/o 


36.7% 
54.6% 


29.4% 


47.3o/o 
25.6% 


20.70/0 
30.0o/o 


19.7% 

44.1% 
58.9% 

30.5% 
20.806 


24.3% 
21.0% 
41.4% 
48.8% 

42.6% 
40.3% 


18.90/0 

4.1o/o 

23.1% 

26.3% 

1.706 

16.0% 
34.506 
3.0% 
22.00/0 
22.906 

5.4o/o 

19.20/0 
31.5% 

18.406 

28.206 
13.2% 

6.50/0 

2.40/o 

26.6% 


3.1% 

36.6% 

3.6% 

18.4% 
3.9% 


10.0% 

4.0% 

27.4% 

28.5% 

26.2% 
36.9% 


6 
Diabetes 

I'erc  enlace  ol  |>eople 
ji  <l  'II  \ears  and  alxive 
with  dialx-tes 
2000 

7 
Ki-search 

Number  D|  publications 
mi  c  ardio\ast  ular  disease 
1991    2001 

8 
Policies  ami 
legislation 

Ix-gal  st.  it  us  K|  smoking 
in  government  building 
2004  or  latest  available  data 

4.7% 

- 

unknown 

4.5% 

- 

not  regulated 

2.6% 

1 

unknown 

8.8% 

- 

banned 

0.9% 

HHHHHHH 

not  regulated 

7.3% 

- 

unknown 

6.1% 

110 

not  regulated 

4.7% 

1 

not  regulated 

6.8% 

710 

restricted 

3.8% 

320 

restricted 

6.8% 

1 

banned 

6.2% 

- 

unknown 

9.1% 

4 

unknown 

4.6% 

3 

restricted 

5.8% 

1 

banned 

9.9% 

3 

restricted 

4.0% 

345 

restricted 

4.2% 

- 

restricted 

3.3% 

1 

unknown 

3.5% 

- 

unknown 

4.9% 

HHHHHHI 

restricted 

3.8% 

- 

banned 

3.6% 

HHHHHHH 

restricted 

4.3% 

307 

banned 

9.4% 

HHHHHHI 

banned 

7.70/0 

18 

banned 

2.7% 

2 

not  regulated 

1.0% 

- 

not  regulated 

1.9% 

HHHHHHI 

restricted 

1.0% 

4 

restricted 

8.8% 

1  237 

restricted 

3.4% 

- 

restricted 

1.0% 

HHHHHHH 

not  regulated 

2.8% 

- 

not  regulated 

5.2% 

53 

restricted 

2.4% 

472 

restricted 

3.6% 

11 

unknown 

1.4% 

- 

unknown 

1.1% 

2 

restricted 

1.4% 

- 

unknown 

6.3% 

HHHHHHI 

not  regulated 

3.3% 

2 

restricted 

3.6% 

HHHHHHH 

restricted 

4.4% 

41 

banned 

6.0% 

15 

restricted 

9.2% 

- 

restricted 

4.3% 

78 

banned 

3.8% 

308 

restricted 

Country 


Afghanistan 

Albania 

Algeria 

Andorra 

Angola 

Antigua  and  Barbuda 

Argentina 

Armenia 

Australia 

Austria 

Azerbaijan 

Bahamas 

Bahrain 

Bangladesh 

Barbados 

Belarus 

Belgium 

Belize 

Benin 

Bhutan 

Bolivia 

Bosnia  and  Herzegovina 

Botswana 

Brazil 

Brunei  Darussalam 

Bulgaria 

Burkina  Faso 

Burundi 

Cambodia 

Cameroon 

Canada 

Cape  Verde 

Central  African  Rep. 

Chad 

Chile 

China 

Colombia 

Comoros 

Congo 

Congo,  Dem.  Rep. 

Cook  Islands 

Costa  Rica 

Cote  d'lvoire 

Croatia 

Cuba 

Cyprus 

Czech  Republic 
Denmark 

85 


World  Data  Table 


Country 

1                                      2                                                         3 
Population                Heart  disease                                        Stroke 

4 
Rheumatic 
heart  diseas 

Number  of  deat 
2002 

Thousands     i           Disability              Mortality                 Disability                 Mortality 
2002          !  DALYS  lost  per  1000        Number            DA  LYS  lost  per  1000            Number 
population                 of  deaths                     population                     of  deaths 
2002                          2002          2003  or  latest  available  data          2002 

Djibouti 

693                     21 

727                           7                                248 

27 

Dominica 

78                       3 

30                           4                                  30 

0 

Dominican  Republic 

8616                     11 

7  271                           9                             4  833 

54 

Ecuador 

12810                       5 

5  826                           5                             4  374 

117 

Egypt 

70  507                     21                     103  829                           8 

35054 

3398 

El  Salvador 

6415                     10 

5328                           4 

1  684 

39 

Equatorial  Guinea 

481                      11 

313                         12 

333 

18 

Eritrea 

3991                      9 

1  326                         10                             1  474 

42 

Estonia 

1  338                    16 

6  235                           9                             2  964 

65 

Ethiopia 

68  961                      10 

32477                          11                           35329 

2  482 

Fiji 

831                      18 

783                         17                                685 

21 

Finland 

5  197                       7 

12488                           4                             4875 

77 

France 

59  850                      3 

46132                           3                           37750 

1  136 

Gabon 

1  306                     11 

1  001                          11                                 951 

57 

Gambia 

1  388                    10 

789                         11 

837 

48 

Georgia 

5177                     23 

26035                         17                           15680 

59 

Germany 

82414                       6                    172717                           4 

79326 

2  241 

Ghana 

20471                       9 

10471                          11                            11  337 

705 

Greece 

10970                       7 

16825                           6                           22694 

10 

Grenada 

80                       9 

85                         13 

91 

1 

Guatemala 

12036                       4 

2  796                           4 

2232 

14 

Guinea 

8359                      11 

4137                         12 

4415 

289 

Guinea-Bissau 

1  449                      11 

783                         13 

• 

844 

52 

Guyana 

764                     12 

791                          18 

880 

8 

Haiti 

8218                       5 

2469                         16 

6764 

62 

Honduras 

6781    ,                  10 

4  544                           8 

2  786 

79 

Hungary 

9923                    13 

29  502                           8 

17  148 

354 

Iceland 

287                       5 

416                           3                                 189 

3 

India 

1  049  549                     20                 1  531  534                         10                         771  067 

103913 

Indonesia 

217  131                      14                   220372                           8                         123  684 

11  660 

Iran,  Isl.  Rep. 

68070                     17 

81  983                           8                           31  768 

1  138 

Iraq 

24510                     19 

22  036                           8                             8  291 

695 

Ireland 

3911                       8 

6  527                           4                             2  650 

51 

Israel 

6304                       4 

5  705                           3                             2  233 

170 

Italy 

57  482                       4 

92  928                           4                           69  075 

1  790 

Jamaica 

2627                       5 

1  877                          11 

3  559 

59 

Japan 

127478                       3 

90  196                           5 

134952 

2  585 

Jordan 

5329                     13 

3  788                           6 

1  428 

127 

Kazakhstan 

15469                     28 

51  948                         17 

26874 

919 

Kenya 
Kiribati 

31  540                       9 
87                       1 

13661                          10 
7                         18 

14843 
81 

360 

o 

Korea,  Dem.  People's  Rep.  of 

22  541                      13 

26  953                           8 

14337 

1  317 

Korea,  Republic  of 

47  430                       3 

15811                           9 

46  151 

202 

Kuwait 

2  443                     10 

940                           3 

213 

7 

Kyrgyzstan 

5  067                     22 

10  850                         22 

8366 

351 

Lao  People's  Dem.  Rep. 

5529                     19 

5539                         12 

3  620 

484 

Latvia 

2329                     17 

9928                         12 

7278 

109 

Lebanon 

3596                     17 

5471                           7 

2072 

119 

86 

5                                              6 

7                                        8 

Smoking  prevalence                  Diabetes 

Research                     Policies  and 

Percentage 

of  people  18               fcroeotage  of  people           Number  of  publications              legislation 

Country 

c.irs  .mil  -ilicnr  \\  ho  smoke            aged  20  vears  and  above         on  cardiovascular  disease 

Legal  status  of  smoking 

2003  or  lute*!  atailahlc  data                       with  diabcU-s                                1991-  2001 

in  government  buildings 

men 

women                                2000 

2004  or  latest  available  data 

- 

2.50/0 

unknown 

Djibouti 

- 

|                   -                       6.20/0 

unknown 

Dominica 

22.1% 

16.2%                      5.2o/o                                  HH 

restricted 

Dominican  Republic 

31.9% 

7.4%                       4.80/0                                        3 

banned                                                        Ecuador 

47.9% 

1  .80/0                        7.20/o 

20 

restricted                                                          Egypt 

- 

3.0%                                                                    unknown                                                  El  Salvador 

- 

3.8o/o 

- 

unknown 

Equatorial  Guinea 

- 

2.8o/o 

4 

not  regulated 

Eritrea 

57.1% 

28.8%                      4.4o/o 

7 

banned 

Estonia 

9.7% 

0.8%                      2.80/0 

4 

not  regulated 

Ethiopia 

47.3% 

14.0%                      8.30/0 

1 

not  regulated 

Fiji 

31.6% 

22.3%                       3.90/o 

331 

banned 

Finland 

42.6% 

33.9o/o                      3.9% 

1  407 

restricted 

France 

- 

1.20/o 

not  regulated 

Gabon 

43.40/0 

6.20/o                       3.3% 

4 

restricted 

Gambia 

61  .4% 

6.30/o 

5.30/0 

159 

not  regulated 

Georgia 

39.0% 

30.90/0 

4.1o/o 

2276 

restricted 

Germany 

1  4.2% 

1  .9% 

3.3o/o 

1 

restricted 

Ghana 

53.5% 

33.6% 

10.30/0 

245 

restricted 

Greece 

- 

- 

7.30/o 

- 

unknown 

Grenada 

24.5% 

3.70/o 

2.70/o 

HHHHHHi 

restricted 

Guatemala 

- 

0.9%                                      3 

banned 

Guinea 

! 

3.1o/o 

HHHHUHJi 

not  regulated 

Guinea-Bissau 

- 

- 

4.20/o 

unknown 

Guyana 

25.2% 

5.4o/o 

4.1o/o 

- 

unknown 

Haiti 

- 

2.70/o 

unknown 

Honduras 

47.2% 

27.70/0 

4.40/o 

103 

banned 

Hungary 

26.5% 

27.1o/o                     3.20/0                                     9                                banned 

Iceland 

34.6% 

3.4o/o                      5.5o/o                                  294 

banned 

India 

59.8% 

5.3o/o                      6JO/o 

4 

restricted 

Indonesia 

33.4% 

3.5o/o 

6.0% 

- 

banned 

Iran,  Isl.  Rep. 

- 

- 

6.1o/o 

1 

unknown 

Iraq 

33.8% 

26.5o/o 

3.2o/o 

142 

restricted 

Ireland 

35.8% 

19jo/o                      6.70/0 

634 

banned 

Israel 

37.9% 

29jo/o 

9.20/0 

1  976 

banned 

Italy 

56.10/0 

21.2% 

5.40/o 

23 

not  regulated 

Jamaica 

52.5% 

12.4% 

6.70/o 

3  769 

restricted 

Japan 

66.80/0 

5.3% 

8.10/0 

6 

banned 

Jordan 

57.50/0 

6.40/o 

4.40/o 

HHHHHH 

restricted 

Kazakhstan 

66.3o/o 

27.30/0 

1.4% 

3 

not  regulated 

Kenya 

•m 

HHHI 

8.60/o 

- 

not  regulated 

Kiribati 

- 

- 

2.50/0 

- 

unknown                        Korea,  Dem.  People's  Rep.  of 

69.5o/o 

5.10/0 

5.60/0 

19 

restricted                                       Korea,  Republic  of 

35.7% 

2.70/0 

9.8o/o 

17 

restricted 

Kuwait 

64.1% 

41.4% 

3.6% 

HHHHHH 

not  regulated 

Kyrgyzstan 

68.90/0 

16.1% 

1.8% 

- 

restricted 

Lao  People's  Dem.  Rep. 

64.50/0 

29.20/0 

4.50A) 

1 

restricted 

Latvia 

60.70/0 

46.90/0 

7.00/0 

65 

restricted 

Lebanon 

87 

World  Data  Table 


Country 

i 

Population 

Thousands 
2002 

2 
Heart  disease 

3 
Stroke 

4 
Rheumatic 
heart  diseas 

Number  of  deal 

2002 

Disability              Mortality                 Disability                 Mortality 

DALYS  lost  per  1000        Number            DALYS  lost  per  1000            Number 
population                 of  deaths                     population                     of  deaths 
2002                            2002        ;  2003  or  latest  available  data           2002 

Lesotho 

1  800 

9 

1  200                         11 

1  299 

24 

Liberia 

3  239 

12 

1  442                          14                               1  559 

130 

Libyan  Arab  Jamahiriya 

5445 

15 

5  309                           6                             1  762 

130 

Lithuania                                                        3  465 

16                      14662                           7                             5089 

186 

Luxembourg 

447 

4 

455                           5                                390 

0 

Macedonia,  Former  Yugos.  Rep.  of                2  046 

9 

2544                          13 

3  772 

41 

Madagascar 

16916 

10 

8327                          11 

9020 

609 

Malawi 

11  871 

10 

6773                          11 

7  249 

106 

Malaysia 

23965 

8                      13445                           7 

10  169 

464 

Maldives 

309 

17 

282                         10 

152 

16 

Mali 

12623 

11 

5406                         13 

5946 

478 

Malta 

393 

9 

865                           4 

338 

6 

Marshall  Islands 

52 

20 

57                         20 

54 

2 

Mauritania 

2807 

11 

1  640                         13 

1  756 

111 

Mauritius 

1  210 

18                        2034                         11 

1  235 

5 

Mexico 

101  965 

6                      51  454                           4 

26478 

1  093 

Micronesia,  Federated  States  of 

108 

12 

64                         14 

69 

2 

Moldova,  Republic  of 

4270 

23                      1 

8559                         15 

7  848 

264 

Monaco 

34 

3 

27                           3 

22 

1 

Mongolia 

2  559 

8 

1  153                         25 

2  515 

145 

Morocco 

30072 

14                     29934                           5 

10607 

808 

Mozambique 

18537 

8 

7  969                         10 

8896 

246 

Myanmar 

48852 

17                      58478                         11 

33  406 

3  746 

Namibia 

1  961 

8 

996                         10 

1  108 

25 

Nauru 

13 

22 

17                         10 

7 

0 

Nepal 

24609 

18                      23314                         10 

11  961 

1  648 

Netherlands 

16067 

5                      1 

9045                           4 

12459 

16 

New  Zealand 

3  846 

7 

6  141                             4 

2  699 

139 

Nicaragua 

5335 

8 

2  680                           7 

1  768 

70 

Niger 
Nigeria 

11  544 
120911 

11                        4423                         13 
11                      64778                         12 

4831 
69932 

439 
4795 

Niue 

Norway 

2 
4514 

10 
5 

1                         12 

8  886                           3 

1 

4817 

0 
103 

Oman 

2768 

17 

1  765                           4 

375 

12 

Pakistan 

149911 

18                    154338                           9 

78  512 

11  604 

Palau 
Panama 

20 
3064 

14 
5 

17                         14 
1  628                           5 

16 
1  489 

0 
30 

Papua  New  Guinea 

5586 

18 

3  994                         10 

1  960 

351 

Paraguay 

5740 

7 

2  606                         10 

2881 

36 

Peru 

26  767 

4                      10615                           4 

8084 

157 

Philippines 

78  580 

10                      4 

5378                           7 

24368 

2812 

Poland 

38622 

10                       7 

7  151                           7 

43032 

1  277 

Portugal 

10049 

5                      1 

0927                           9 

20069 

189 

Qatar 

601 
22387 

9                           238                           4 
13                      60718                         13 

75 
52272 

4 
566 

Russian  Federation 

144082 

27                    674881                          19 

517424 

8  126 

Rwanda 

8272 

10                        3  493                         12 

3811 

101 

Saint  Kitts  and  Nevis 

42 

10 

46                         19 

84 

0 

88 

5 
moking  prevalence 
Percentage  ol  people  IN 

ars  and  lbove  \\lio  smoke 
(Hb1  i>r  Aiiiv  ,ir.;i/<iMr  i/iitj 
nu'ii                    women 

6                                          7 
Diabetes                          Research 

Percentage  of  people              Numl>iT  of  publications 
aged  2(1  ve.irs  ami  abo\e         on  cardiovascular  disease 
\\ithdiabetcs                                1W1    .'()()/ 

2000 

8 
Policies  and 
legislation 

;      Legal  status  of  smoking 
in  government  buildings 

o                                          o 
2004  or  latest  available  Jata 

Country 

- 

- 

3.1% 

unknown                                                       Lesotho 

- 

i 

3.10/0 

unknown 

Liberia 

- 

pHHHi 

3.1%                                                                     banned 

Libyan  Arab  Jamahiriya 

46.4% 

15.90/0 

4.2o/o                                     5                              restricted 

Lithuania 

41  .4% 

30.20/0 

3.6o/o 

3 

restricted 

Luxembourg 

- 

; 

3.8o/o 

5                               banned                 Macedonia,  Former  Yugos.  Rep.  of 

- 

- 

1.4o/o 

2                           not  regulated                                             Madagascar 

31.0% 

;         7.40/0 

1.1% 

1                          not  regulated 

Malawi 

52.40/0 

3.00/0 

7.60/o 

16                               banned 

Malaysia 

- 

- 

5.0% 

banned 

Maldives 

26.9% 

4.70/o 

2.90/o 

restricted 

Mali 

DH^MBBMH 

- 

13.90/0 

5                           not  regulated 

Malta 

- 

8.60/o 

9                                banned 

Marshall  Islands 

25.0% 

i             4.30/o 

2.80/o 

not  regulated 

Mauritania 

54.70/0 

3.10/0 

14.6% 

2                              restricted 

Mauritius 

36.5% 

14.3% 

3.90/o 

201                              restricted 

Mexico 

HH1 

IHHHi 

8.6% 

not  regulated                Micronesia,  Federated  States  of 

- 

~ 

5.90/o 

I              restricted                                   Moldova,  Republic  of 

•• 

8.80/0 

7 

unknown 

Monaco 

46.20/0 

7.30/0 

2.50/o 

1                              restricted 

Mongolia 

32.6Q/0 

0.60/o 

2.6o/o 

7 

restricted 

Morocco 

- 

- 

1.6o/o 

1                               unknown 

Mozambique 

55.50/0 

12.20/0 

2.00/0 

mwmuam 

unknown 

Myanmar 

33.80/0 

16.1% 

3.10/0 

not  regulated 

Namibia 

56.80/0 

64.70/0 

27.80/0 

banned 

Nauru 

61.5% 

34.60/0 

3.9%                                     3                                banned 

Nepal 

38.30/0 

32.80/0 

3.5%                                   917 

restricted 

Netherlands 

28.10/0 

28.70/0 

6.70/0                                 131                              restricted 

New  Zealand 

HHI 

HHHHH 

2.90/0 

restricted 

Nicaragua 

- 

- 

2.50/0 

- 

unknown 

Niger 

16.30/0 

3.60/o 

3.4% 

18 

banned 

Nigeria 

36.80/0 

14.00/0 

6.30/0 

- 

restricted 

Niue 

40.3o/o 

39.00/0 

3.9% 

185 

restricted 

Norway 

23.60/0 

2.90/o 

9.9o/o 

19 

unknown 

Oman 

30.30/0 

3.80/o 

7jo/o 

12 

banned 

Pakistan 

50.9o/o 

22.6% 

8.60/0 

- 

banned 

Palau 

35.1% 

17.70/0 

3.5% 

1 

unknown 

Panama 

48.9% 

- 

6.50/o 

3 

banned 

Papua  New  Guinea 

45.80/0 

15.60/0 

3.70/o 

restricted 

Paraguay 

- 

- 

5.20/0 

3                              restricted 

Peru 

59.6o/o 

13.8% 

7.10/0 

2                               restricted 

Philippines 

51.50/0 

27.90/0 

4.1o/o 

187                               banned 

Poland 

44.20/0 

19jo/o 

8.60/o 

51 

restricted 

Portugal 

- 

- 

10.10/0 

7                              unknown 

Qatar 

33.3o/o 

10.80/0 

6.6o/o 

16 

unknown 

Romania 

58.10/0 

15.80/0 

4.20/o 

13                               banned                                        Russian  Federation 

HHI 

HHHH 

0.9o/o 

not  regulated                                                   Rwanda 

- 

- 

7.3% 

unknown                                   Saint  Kitts  and  Nevis 

89 


World  Data  Table 


Country 

i 

Population 

Thousands 
2002 

2 
Heart  disease 

Stroke 

4 
Rheumati 
heart  disea 

Number  ot  tie 
2002 

Disability 

DALYS  lost  per  1000 

population 
2002 

Mortality                 Disability                 Mortality 

Number            DALYS  lost  per  1000            Number 
of  deaths                     population                     of  deaths 
2002           2003  or  latest  available  data           2002 

Saint  Lucia 

148 

6 

71 

11                                 120 

4 

Saint  Vincent  and  Grenadines 

119                       9 

103                               10                                           88 

2 

Samoa 

176                     14 

117 

14                                128 

3 

San  Marino 

27                       5 

40                           3                                  26 

1 

Sao  Tome  and  Principe 

157 

7 

81                          10                                 107 

2 

Saudi  Arabia 

23  520 

17 

16438                           4                             3818 

126 

Senegal 

9855 

10 

3838                         12                             4154 

355 

Serbia  and  Montenegro 

10535 

12 

23  610                         12                           21  756 

238 

Seychelles 

80 

7 

54                           2                                   15 

1 

Sierra  Leone 

4764 

13 

2813                         15                             3035 

216 

Singapore 

4  183 

7 

3  946                           3                              1  716 

39 

Slovakia 

5398 

12 

14609                           5 

4445 

131 

Slovenia 

1  986 

6 

2803                          6 

2003 

87 

Solomon  Islands 

463 

12 

213                         13 

220 

6 

Somalia 

9480 

19 

6818                         13 

4426 

333 

South  Africa 

44759 

9 

27013                          11 

30306 

792 

Spain 

40977 

4 

45018                           3 

34880 

1  738 

Sri  Lanka 

18910 

8 

16297                           7 

13  348 

175 

Sudan 

32  878 

15 

28  458                         10 

16532 

800 

Suriname 

432 

13 

397 

12 

362 

4 

Swaziland 

1  069 

8 

529 

8 

499 

13 

Sweden 

8867 

5 

20  122                           3 

9  984 

143 

Switzerland 

7  171 

4 

10  746                           2 

4  508 

112 

Syrian  Arab  Republic 
Tajikistan 

17381 
6  195 

13 
23 

11  168 
11  447 

11 
7 

7  675 
3  048 

1  715 
419 

Tanzania,  United  Republic  of                      36  276 
Thailand                                                     62  193 

10 
6 

14720 

28425 

12 
5 

16  115 
24810 

439 
456 

Timor-Leste 

739                     18 

635 

10                                315 

49 

Togo 

4801 

10 

2474 

12 

2675 

175 

Tonga 

103 

10 

70 

12                                  79 

2 

Trinidad  and  Tobago 

1  298 

15 

2  156 

10                             1  253 

23 

Tunisia 

9728 

15 

12956                          6 

4798 

I             298 

Turkey 

70318 

16 

102  552 

13 

62  782 

1  584 

Turkmenistan 

4794 

34 

11  671 

7 

2  182 

;         221 

Tuvalu 

10 

18 

11 

20 

11 

0 

Uganda 

25004 

10 

10  163 

11 

11  043 

288 

Ukraine 

48  902                     28 

335610 

13 

126  117 

3085 

United  Arab  Emirates 

2937                     17 

2235                          4 

363 

16 

United  Kingdom 

59  068                       7 

120530                           4 

59322 

1  712 

United  States  of  America                          291038 

8 

514450                           4 

163  768 

3  479 

Uruguay 

3391 

6 

3980 

7 

3  773 

32 

Uzbekistan 

25705 

24 

55693 

12 

23  436 

1  558 

Vanuatu 

207 

13 

120 

13 

122 

3 

Venezuela 

25226 

10 

17967 

5 

8  720 

208 

Viet  Nam 

80278 

10 

66  179 

8 

58308 

4210 

Yemen 

19315 

22 

16217                           9 

6464 

743 

Zambia 

10698 

8 

4  153                           9 

4604 

135 

Zimbabwe 

12  835 

8 

5752 

10 

6264 

158 

90 

5                                            6 
Smoking  prevalence                   Diabetes 

1'iTii'iitasje  of  people  18                    IVrivntaiy  <>l  proplr 
M-ars  aiul  above  \vlio  smoke            aged  20  years  and  alxwe 
-003  IT  lau-it  iiuJi/iiWi'  Juta                       with  di.ibrh-s 
w,,nu-n                                   ^00 

7 
Research 

Number  of  publications 
on  cardiovascular  disease 
1991    2001 

8 
Policies  and 
legislation 

Legal  status  of  smoking 
in  government  buildings 
2004  or  latest  available  data 

Country 

34.6% 

5.0%                        6.2% 

restricted 

Saint  Lucia 

34.6% 

5.6%                        7.3% 

- 

unknown                      Saint  Vincent  and  Grenadines 

67.4% 

28.8%                        6.1o/o 

HHHHHHi 

banned 

Samoa 

- 

-    ,                    9.2o/o 

- 

unknown 

San  Marino 

•m 

0.90/o 

HHHHHMHI 

not  regulated 

Sao  Tome  and  Principe 

29.1% 

1.20/0                      9.3o/o                                     51 

banned                                                 Saudi  Arabia 

21.2% 

1.50/o                      3.4o/o 

3 

not  regulated                                                    Senegal 

55.5% 

51  .80/0                       4.20/o 

21 

not  regulated 

Serbia  ft  Montenegro 

32.5% 

15.00/0                      14.6o/o 

HBHBHMH93 

unknown 

Seychelles 

- 

3.3% 

- 

unknown 

Sierra  Leone 

23.7% 

3.2%                      11.40/0 

76 

restricted 

Singapore 

42.3% 

28.00/0                       3.9% 

25 

banned 

Slovakia 

32.7% 

20.80/0                       4.30/o 

34 

restricted 

Slovenia 

- 

- 

6.40/0 

- 

restricted 

Solomon  Islands 

HUH 

- 

2.70/0 

HBHHHBHi 

unknown 

Somalia 

43.4% 

13.9%                      3.40/o 

77 

restricted 

South  Africa 

43.9% 

31.20/0                      8.70/0                                   689 

restricted 

Spain 

38.7% 

3.1%                       5.4o/o                                       6 

banned 

Sri  Lanka 

27.7% 

2.7%                      2.9o/o 

- 

restricted 

Sudan 

- 

-    j                   3.8% 

- 

not  regulated 

Suriname 

19.6% 

4.9o/o                      2.9o/o 

HBHHHHI 

not  regulated 

Swaziland 

21.3% 
37.6% 

24.90/0 
28.3% 

4.3% 
3.9% 

654 
440 

banned 
restricted 

Sweden 
Switzerland 

44.0% 

16.70/0 

8.20/0 

banned 

Syrian  Arab  Republic 

IHH 

HHBSHI 

3.1o/o 

- 

not  regulated 

Tajikistan 

48.9% 

7.20/o 

1  .30/0 

_ 

not  regulated 

Tanzania,  United  Republic  of 

32.2% 

2.7o/o 

3.80/o 

59 

restricted 

Thailand 

- 

- 

- 

- 

unknown 

Timor-Leste 

Bin 

HHMI 

3.1% 

* 

not  regulated 

Togo 

62.10/0 

14.20/0    i                    6.30/0 

- 

banned 

Tonga 

- 

- 

7.30/o 

5 

not  regulated 

Trinidad  and  Tobago 

52.90/0 

2.50/o 

2.90/o 

8 

restricted 

Tunisia 

51.10/0 

18.50/0 

7.30/o 

578 

banned 

Turkey 

- 

- 

3.20/o 

- 

banned 

Turkmenistan 

BBH 

- 

6.3% 

HHHHHHi! 

banned 

Tuvalu 

33.40/0 

7.1o/o 

1.1% 

2 

restricted 

Uganda 

55.5% 

14.70/0 

4.40/o 

19 

restricted 

Ukraine 

27.6% 

4.00/0 

20.5o/o 

8 

restricted                                  United  Arab  Emirates 

34.60/0 

34.40/0                       3.90/o 

2  667 

not  regulated 

United  Kingdom 

27.80/0 

22.3%                       8.80/0 

12  502 

restricted 

United  States  of  America 

39.40/0 

30.80/0                        6.80/o 

2 

restricted 

Uruguay 

28.70/0 

1  .40/o                       3.20/o                                         1 

not  regulated 

Uzbekistan 

47.90/0 

4.80/o                        6.9% 

restricted 

Vanuatu 

51.90/0 

20.5o/o                     4.3%                                                                    unknown 

Venezuela 

53.2% 

3.0% 

1.80/o 

banned 

Viet  Nam 

60.00/0 

29.0o/o 

4.40/o 

unknown 

Yemen 

21.40/0 

8.8% 

1  .6% 

restricted 

Zambia 

32.2o/o 

4.6o/o 

2-QO/o                                        2 

unknown                                                   Zimbabwe 

91 

Glossary    of  terms  used  in  this  publication 


ACE  inhibitors:  angiotensin-converting-enzyme 
inhibitors.  Drugs  used  to  treat  high  blood  pressure,  and 
to  aid  healing  after  a  heart  attack. 

Angina  (angina  pectoris):  pain  or  discomfort  in  the 
chest  that  occurs  when  part  of  the  heart  does  not 
receive  enough  blood.  Typically,  it  is  precipitated  by 
effort  and  relieved  by  rest. 

Angioplasty:  a  non-invasive  surgical  procedure  used 
to  open  up  blockages  in  blood  vessels,  particularly  the 
coronary  arteries  that  feed  the  heart.  Often  performed 
with  either  a  balloon  or  a  wire  mesh  (stent). 

Anticoagulant:  medication  that  delays  the  clotting 
(coagulation)  of  blood. 

Arrhythmia:  a  change  in  the  regular  beat  or  rhythm  of 
the  heart.  The  heart  may  seem  to  skip  a  beat,  or  beat 
irregularly,  or  beat  very  fast  or  very  slowly. 

Arteriosclerosis:  a  general  term  for  the  hardening  of 
the  arteries. 

Asymptomatic:  without  symptoms.  This  term  may 
apply  either  to  healthy  persons  or  to  persons  with 
preclinical  (prior  to  clinical  diagnosis)  disease  in  whom 
symptoms  are  not  yet  apparent. 

Atherosclerosis:  one  form  of  arteriosclerosis,  where 
the  hardening  and  narrowing  of  the  arteries  is  caused  by 
the  slow  build-up  of  fatty  deposits  on  the  inside  lining. 

Atrial  fibrillation:  a  common  heart  rhythm  disorder 
in  which  the  two  small  upper  chambers  of  the  heart 
(the  atria)  quiver  instead  of  beating  effectively.  This 
quivering  makes  the  heart  less  efficient,  allows  blood  to 
pool  and  form  clots,  and  predisposes  to  stroke. 

Blood  pressure:  the  force  of  the  blood  pushing 
against  the  walls  of  arteries.  Blood  pressure  is  given  as 
two  numbers:  systolic  pressure  (the  pressure  while  the 
heart  is  contracting)  and  diastolic  pressure  (the  pressure 
when  the  heart  is  resting  between  contractions). 

Body  mass  index  (BMI):  a  measure  of  weight  in 
relation  to  height.  It  is  calculated  as  weight  (in 
kilograms)  divided  by  the  square  of  height  (in  metres). 
A  BMI  of  less  than  25  is  considered  normal,  25-30  is 
overweight,  and  greater  than  30  defines  obesity. 

Cardiovascular  disease  (CVD):  any  disease  of  the 
heart  or  blood  vessels,  including  stroke  and  high  blood 

o  o 

pressure. 


Carotid  stenosis:  narrowing  of  the  carotid  arteries, 

O 

the  main  arteries  in  the  neck  that  supply  blood  to  the 
brain. 

Cerebrovascular  disease:  also  called  a  stroke  or  the 
brain  equivalent  of  a  heart  attack.  A  condition  in  which  a 
blood  vessel  in  the  brain  bursts  or  is  clogged  bv  a  blood 

oo  7 

clot,  leading  to  inadequate  blood  supply  to  the  brain  and 
death  of  brain  cells. 

Cholesterol:  a  waxy  substance  that  circulates  in  the 
bloodstream. 

Cholesterol  plaques:  deposits  of  fat,  cholesterol, 
cellular  waste  products,  calcium  and  other  substances 
that  build  up  on  the  inner  lining  of  an  arterv. 

1  O  J 

Congestive  heart  failure:  a  condition  in  which  the 
heart  cannot  pump  enough  blood  to  meet  the  needs  of 
the  body's  other  organs. 

Coronary  artery  bypass  surgery  (CABG):  A  type 
of  heart  surgery  that  re-routes  blood  around  clogged 
arteries  —  or  "bypasses"  them  -  to  improve  the  supply  of 
blood  and  oxygen  to  the  heart. 

Coronary  heart  disease:  heart  disease  in  which  the 
coronary  arteries  are  narrowed  and  the  supply  of  blood 
and  oxygen  to  the  heart  therefore  decreased.  Also 
called  coronary  artery  disease  or  ischaemic  heart 
disease.  It  includes  heart  attack  and  angina. 

o 

Developing  country,  high  mortality:  a  developing 
country  with  high  child  mortality  and  high  or  very  high 
adult  mortality. 

Developing  country,  low  mortality:  a  developing 
country  with  low  child  mortality  and  low  adult 
mortality. 

Diabetes  mellitus:  a  chronic  disease  due  to  either 
insulin  deficiency  or  resistance  to  insulin  action  or  both, 
and  associated  with  hyperglycaemia  (elevated  blood 
glucose  levels). 

Direct  costs:  costs  associated  with  an  illness  that  can 
be  attributed  to  a  medical  service,  procedure, 
medication,  etc.,  such  as  X-ray  examination, 
pharmaceutical  drugs  (for  example,  insulin),  surgery,  or 
a  clinic  visit. 

Disability  adjusted  life  years  (DALYs):  a  measure 
of  overall  burden  of  a  disease  by  combining  the  years  of 
potential  life  lost  due  to  premature  death  and  the  years 
of  productive  life  lost  due  to  the  disability.  One  DALY 
is  one  lost  year  of  healthy  life. 


92 


Epidemic:  tin-  occurrence1  in  a  community  or  region  of 
cases  ol  an  illness,  specific  health-related  behaviour,  or 
other  health-related  events  clearly  in  excess  of  what 
would  normally  be  expected. 

Health:  a  state  of  complete  physical,  mental,  and  social 
\u-ll  being  and  not  merely  the  absence  of  disease  or 
infirmity. 

HDL  (high-density  lipoprotein)  cholesterol:  the 

so-called  "yood  cholesterol".  HDL  helps  remove 
cholesterol  from  the  blood  vessels.  High  levels  of  blood 
HDL  protect  against  heart  disease. 

Heart  attack  (myocardial  infarction):  death  of 
part  ol  the  heart  muscle  as  a  result  of  a  coronary  artery 
becoming  completely  blocked,  usually  by  a  blood  clot 
(thrombus),  resulting  in  lack  of  blood  flow  to  the  heart 
muscle  and  therefore  loss  of  needed  oxygen. 

Heart  failure:  see  Congestive  heart  failure. 

High  blood  pressure:  a  systolic  blood  pressure  of 
140  mmHg  or  greater  or  a  diastolic  pressure  of  90 
mmHg  or  greater. 

Homocysteine:  an  amino  acid  produced  by  the  body. 
Elevated  levels  of  homocvsteine  in  the  blood  can 
damage  blood  vessels  and  disrupt  normal  blood 
clotting,  and  possibly  increase  the  risk  of  heart  attack, 
stroke,  and  peripheral  vascular  disease. 

Indirect  costs:  costs  associated  with  an  illness  that 
occur  because  an  individual  or  familv  members  cannot 
work  at  their  usual  jobs,  because  of  premature  death, 
sickness,  or  disability. 

Ischaemic  heart  disease:  see  Coronary  heart 
disease. 

LDL  (low-density  lipoprotein)  cholesterol:  the 

so-called  "bad  cholesterol".  High  levels  of  LDL  put 
people  at  risk  of  heart  attack. 

Lipid:  fat  or  fat-like  substance,  such  as  cholesterol, 
present  in  blood  and  body  tissues. 

MET:  metabolic  equivalent;  a  measure  of  energy 
expenditure.  One  MET/min  is  the  amount  of  energy 
expended  while  sitting  quietly  at  rest  for  one  minute. 

Obesity:  a  condition  characterized  by  excessive  body 
fat.  Usually  defined  as  a  body  mass  index  greater  than 
30. 

Peripheral  vascular  disease:  disease  of  certain 
blood  vessels  outside  the  heart  or  disease  of  the  lymph 
vessels,  for  example  the  arteries  supplying  the  limbs, 
which  leads  to  inadequate  blood  supply  and  claudication 
(intermittent  pain  on  exercise  such  as  walking). 


Physical  activity:  bodily  movement  that  substantially 
increases  energy  expenditure. 

Premature  death:  death  that  occurs  at  an  age  earlier 
than  the  average  life  expectancy  for  the  population. 

Primary  prevention:  a  strategy  that  helps  to  prevent 
the  onset  of  a  disease  or  condition  in  people  who  are  at 
risk  but  do  not  already  have  the  disease  or  condition. 
Examples  are  promotion  of  exercise  in  the  general 
population,  smoking  prevention  in  young  people,  and 
also  the  treatment  and  control  of  high  blood  pressure  as 
a  strategy  for  primary  prevention  of  stroke. 

Rheumatic  heart  disease:  damage  to  the  heart 
valves  and  other  heart  structures  from  inflammation  and 
scarring  caused  by  rheumatic  fever.  Rheumatic  fever 
begins  with  a  sore  throat  due  to  streptococcal  infection. 

Secondary  prevention:  a  strategy  that  helps  to 
prevent  recurrent  disease  or  complications  in  people 
who  already  have  the  disease.  For  example,  the  use  of  a 
daily  dose  of  aspirin  by  heart  attack  survivors  is  an 
effective  strategy  for  preventing  a  second  heart  attack. 

Sedentary:  denotes  a  person  who  is  relatively  inactive 
and  has  a  lifestyle  characterized  by  a  lot  of  sitting. 

Stent:  a  device  used  to  support  tissues  while  healing 
takes  place.  A  stent  can  keep  "tube-shaped"  structures, 
such  as  blood  vessels,  open  after  a  surgical  procedure. 
Anintraluminal  coronary  artery  stent  is  a  small,  self- 
expanding,  stainless  steel  mesh  tube,  which  is  placed 
within  a  coronary  artery  to  keep  the  vessel  open. 

Stroke:  the  brain  equivalent  of  a  heart  attack. 
A  condition  in  which  a  blood  vessel  in  the  brain  bursts 
(haemorrhagic  stroke)  or  is  clogged  (embolic  or 
ischaemic  stroke)  by  a  blood  clot.  This  leads  to 
inadequate  blood  supply  to  the  brain  and  death  of  the 
brain  cells,  and  usually  results  in  temporary  or 
permanent  neurological  deficits. 

Transient  ischaemic  attack  (TIA):  small  stroke-like 
event,  which  resolves  in  a  day  or  less.  It  is  often  a 
warning  sign  of  an  impending  stroke. 

Triglyceride:  the  chemical  form  in  which  most  fat 
exists  in  food  and  in  the  body. 


93 


Sources 


PART  1  CARDIOVASCULAR 
DISEASE 

1  Types  of  cardiovascular  disease 

Deaths  from  cardiovascular  diseases 

Mortality  and  burden  of  disease  estimates  for 
countries  provided  by  Colin  Mathers  (Evidence  and 
Information  for  Policy,  WHO)  from  analyses 
prepared  for  The  World  Health  Report  2003. 

Global  deaths  from  CVD 

World  Health  Organization.  The  World  Health  Report 
2003:  shaping  the  future.  Geneva,  WHO,  2003, 
Annex  Table  2:156. 

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future.  Geneva,  WHO,  2003,  Annex  Table  2:156. 

2  Rheumatic  fever  and  rheumatic 
heart  disease 

Map:  Deaths  from  rheumatic  heart  disease 

Mortality  and  burden  of  disease  estimates  for 
countries  provided  by  Colin  Mathers  (Evidence  and 
Information  for  Policy,  WHO)  from  analyses 
prepared  for  The  World  Health  Report  2003. 

Rheumatic  heart  disease  in  children 

Carapetis  JR.  The  current  evidence  for  the  burden  of 
group  A  streptococcal  diseases.  A  review  of  WHO 
activities  in,  the  burden  of,  and  the  evidence  for  strategies 
to  control  group  A  streptococcal  diseases.  Geneva, 
WHO,  2004. 

Deaths  from  rheumatic  fever  and  rheumatic 
heart  disease  in  the  Aboriginal  and  non- 
Aboriginal  populations  of  Australia 

Carapetis  JR,  Currie  BJ.  Mortality  due  to  acute 
rheumatic  fever  and  rheumatic  heart  disease  in  the 
Northern  Territory:  a  preventable  cause  of  death  in 
Aboriginal  people.  Australian  and  New  Zealand  journal 
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Clipboard 

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Text 

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2003,  327:631    63  (editorial). 

WHO.  The  World  Health  Report  2003:  shaping  the 
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Veasy  LG,  Hill  HR.  Immunologic  and  clinical 
correlations  in  rheumatic  fever  and  rheumatic  heart 
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PART  2  RISK  FACTORS 

3  Risk  factors 

Leading  risk  factors 

WHO.  Leading  10  selected  risk  factors  as  percentage 
cause  of  disease  burden  measured  in  DALYs.  The 
World  Health  Report  2002:  reducing  risks,  promoting 
healthy  life.  Geneva,  WHO,  2002,  162. 

Contributory  factors 

WHO.  Quantifying  selected  major  risks  to  health. 
The  World  Health  Report  2002:  reducing  risks,  promoting 
healthy  life.  Geneva,  WHO,  2002,  57-61. 

Clipboard 

Beaglehole  R,  Magnus  P.  The  search  for  new  risk 
factors  for  coronary  heart  disease:  occupational  therapy 
for  epidemiologists?  International  journal  of  epidemiology , 
2002,  3 1(6):  11 17  22;  author  reply  1134-5. 

Text 

Inter-Society  Commission  for  Heart  Disease 
Resources  A:  Primary  prevention  of  the 
atherosclerotic  diseases.  Circulation,  1970, 
42:A55-A95. 


94 


4  Risk  factors  start  in  childhood  and 
youth 

Maps:  Early  starters;  Clipboard 

Global  Youth  Collaborating  Group.  Special  report: 
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findings  from  the  Global  Youth  Tobacco  Survey. 
Journal  of  school  health,  2003,  73(6):207   21  5. 
Detailed  country  information  available  at: 
http://www.cdc.gov/tobacco/global/GYTS.htm 

Overweight  trends  in  the  USA 

CDC,  National  Center  for  Health  Statistics.  Health, 
United  States,  2003  with  Chartbook  on  trends  in  the 
health  of  Americans.  Hyattsville,  MD,  2003.  BMI  at 
or  above  the  sex-age-specific  95th  percentile 
http://www.cdc.gov/nchs/data/hus/tables/2003/ 
03hus069.pdf 

Overweight  youth 

Lissau  I,  Overpeck  MD,  Ruan  WJ,  Due  P,  Holstein 
BE,  Hedinger  M,  and  the  Health  Behaviour  in 

o 

School-aged  Children  Working  Group.  Body  mass 
index  and  overweight  in  adolescents  in  1  3  European 
countries,  Israel,  and  the  United  States.  Archives  of 
pediatric  and  adolescent  medicine,  2004,  158:27—33. 
Table  3.  Prevalence  of  BMI  at  or  above  the  95th 
percentile  (overweight)  by  sex  (self-reported). 

Wow:  USA 

Kimm  SYS  et  al.  Decline  in  physical  activity  in  black 
girls  and  white  girls  during  adolescence.  New  England 
journal  of  medicine,  2002,  347:709-15. 

Clipboard 

Overweight:  WHO  Fact  Sheet,  Global  Strategy  on 
Diet,  Physical  Activity  and  Health.  Obesity  and 
overweight.  Geneva,  WHO,  2003 

o 

http://www.who.int/hpr/gs.facts.shtml 

Text 

Zimmet  P.  The  burden  of  type  2  diabetes:  are  we 
doing  enough?  Diabetes  and  metabolism,  2003, 
29(4Pt2):6S9-6S18. 

Kitagawa  T,  Owada  M,  Urakami  T,  Yamauchi  K. 
Increased  incidence  of  non-insulin  dependent  diabetes 
mellitus  among  Japanese  schoolchildren  correlates 
with  an  increased  intake  of  animal  protein  and  fat. 
Clinical  pediatrics  (Philadelphia),  1 998,  37(2):  111115. 


Likitmaskul  S,  Kiattisathavee  P,  Chaichanwatanakul 
K,  Punnakanta  L,  Angsusingha  K,  Tuchinda  C. 
Increasing  prevalence  of  type  2  diabetes  mellitus  in 
Thai  children  and  adolescents  associated  with 
increasing  prevalence  of  obesity.  Journal  of  pediatric 
endocrinology  and  metabolism,  2003,  16(l):71-77. 

Berenson  GS,  Srinivasan  SR,  Bao  W,  Newman  WP 
3rd,  Tracy  RE,  Wattigney  WA.  Association  between 
multiple  cardiovascular  risk  factors  and 
atherosclerosis  in  children  and  young  adults.  The 
Bogalusa  Heart  Study.  New  England  journal  of  medicine, 
1998,  338(23):1650-1656. 

5  Risk  factor:  blood  pressure 

Maps:  Blood  Pressure 

WHO  Global  NCD  InfoBase  [online  database]. 

Geneva,  WHO,  2004 

http :  /  /  www.  who.  int /ncd_sur  veillance  /  infobase  / 

High  blood  pressure  in  the  USA 

Trends,  USA,  1960-2000;  Health,  United  States 
2002;  Table  68.  Hypertension  among  persons  20 
years  of  age  and  over,  according  to  sex,  age,  race, 
and  Hispanic  origin:  United  States, 
1960-62,1971-74,  1976-80,  1988-94,  and 
1999-2000.  Referencing  Centers  for  Disease 
Control  and  Prevention,  National  Center  for  Health 
Statistics,  National  Health  and  Nutrition  Examination 
Survey,  Hispanic  Health  and  Nutrition  Examination 
Survey  (1982-84),  and  National  Health  Examination 
Survey  (1960-62) 
http://www.cdc.gov/nchs/data/hus/hus02.pdf 

Blood  pressure  changes  with  age  in  the 
Gambia 

van  der  Sande  MA,  Bailey  R,  Faal  H  et  al. 
Nationwide  prevalence  study  of  hypertension  and 
related  non-communicable  diseases  in  The  Gambia. 

Tropical  medicine  and  international  health,  1997, 
2(11):1039-1048. 

Blood  pressure  in  India 

Singh  RB,  Suh  IL,  Singh  V.  et  al.  Hypertension  and 
stroke  in  Asia:  prevalence,  control  and  strategies  in 
developing  countries  for  prevention.  Journal  of  human 
hypertension,  2000,  14:749-763. 


95 


High  blood  pressure  by  years  of  education  in 
South  Africa 

South  Africa  Demographic  and  Health  Survey  1 998 
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Text 

Vasan  RS,  Larson  MG,  Leip  EP,  Evans  JC,  O'Donncll 
CJ,  Kannel  WB,  Levy  D.  Impact  of  high-normal 
blood  pressure  on  the  risk  of  cardiovascular  disease. 
New  England  journal  of  medicine,  2001 , 
345:1291    1297. 

World  Hypertension  League.  The  high  blood 
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Americans 
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Huxley  R,  Neil  A,  Collins  R.  Unravelling  the  fetal 
origins  hypothesis:  is  there  really  an  inverse 
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Systolic  blood  pressure.  British  medical  journal,  2002, 
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Sleight  P.  Fact  sheet:  isolated  hypertension  (ISH). 
World  Hypertension  League 
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Weinberger  MH,  Miller  JZ,  Luft  FC,  Grim  CE, 
Fineberg  NS.  Definitions  and  characteristics  of 

o 

sodium  sensitivity  and  blood  pressure  resistance. 
Hypertension,  1986,  8(2):  1 27-1  34. 

He  J,  Ogden  LG,  Vupputuri  S,  Bazzano  LA,  Loria  C, 
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o 

Journal  of  the  American  Medical  Association,  1999, 
282:2027-2034. 


6  Risk  factor:  lipids 

Map:  Cholesterol 

WHO  Global  NCD  InfoBase  [online  database]. 

Geneva,  WHO 

http :  /  /  www.  who.  int  /  ncd_sur  veillance  /  infobase  / 


Current  recommended  lipid  levels 

De  Backer  G,  Ambrosioni  E,  Borch-Johnsen  K  et  al.; 
Third  Joint  Force  of  European  and  other  Societies  on 
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Third  Report  of  the  National  Cholesterol  Education 

Program  (NCEP)  Expert  Panel  on  Detection, 

Evaluation,  and  Treatment  of  High  Blood  Cholesterol 

in  Adults  (Adult  Treatment  Panel  III)  final  report. 

Circulation,  2002,  106:3143-3421 

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Trends  in  cholesterol  levels  in  Beijing,  China 

Tolonen  H,  Kuulasmaa  K,  Ruokokoski.  MONICA 
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Wow:  USA 

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Text 

American  Heart  Foundation.  About  cholesterol 
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7  Risk  factor:  tobacco 

Maps:  Smoking  prevalence 

WHO  Global  NCD  InfoBase  [online  database]. 

Geneva,  WHO 

http: //www.  who. int/ncd_surveillance/infobase/ 

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Price  JF,  Mowbray  PI,  Lee  AJ,  Rumley  A,  Lowe  GD, 
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Smoking  and  stroke:  a  causative  role.  Heavy  smokers 
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Cole  CW,  Hill  GB,  Farzad  E,  Bouchard  A,  Moher  D, 
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o  o 

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PART  3  THE  BURDEN 

13  Global  burden  of  coronary  heart 
disease 

Map:  Healthy  years  of  life  lost  to  coronary 
heart  disease 

Mortality  and  burden  of  disease  estimates  for 
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Disease  burden  in  men;  in  women 

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Clipboard;  Text 

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xtWvxSNaGHCVd2ranocYJpC  1 42976445789882471 
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Text 

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14  Deaths  from  coronary  heart 
disease 

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Mortality  and  burden  of  disease  estimates  for 
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Deaths  from  coronary  heart  disease 
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Wow:  3.8  million  men... 

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cardiovascular  disease.  Medscape  cardiology, 

24  January  2002 

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bLogicSession=Pj4P2wsr6 1 1  rYWKbLSDskpUMbsjmJ 

xtWvxSNaGHCVd2ranocYJpC  1 42976445789882471 

33/1 84161 393/6/7001/7001/7002/7002/7001 /-I 

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15  Global  burden  of  stroke 

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102 


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16  Deaths  from  stroke 

Map:  Struck  down 

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17  Economic  costs 

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Global  costs  of  heart  disease  medication 

Kmietowicz  Z.  News:  WHO  warns  of  heart  disease 
threat  to  developing  world.  British  medical  journal, 
2002,  325:853. 

Global  costs  of  diabetes 

International  Diabetes  Federation 

http://www.idf.org/home/index.cfmPunode 

=3B9691D3-C026-2FD3-87B7FAOB63432BA3 

Latin  America  and  the  Caribbean 

PAHO  cites  impact  of  diabetes  in  Latin  America 
http:  // www.unwire.org 


103 


USA,  Australia,  Europe 

Reuters.  Asia-Pacific  Type  2  Diabetes  Policy  Group: 
spread  of  diabetes  in  Asia  alarms  experts.  South  China 
Morning  Post,  1  May  2002,  10. 

USA 

Runners  beat  around  the  Bush.  Knight  Ridder  in 

o 

Washington.  South  China  Morning  Post, 
24  June  2002,  13. 

Diet,  nutrition  and  the  prevention  of  chronic  diseases: 
report  of  a  Joint  WHO/FAO  Expert  Consultation.  Geneva, 
WHO,  2003  (WHO  Technical  Report  Series  No. 
916):61. 

Elliot  A.  US  food  industry  ensures  that  consumers 
are  not  told  to  eat  less.  British  medical  journal,  2003, 
327:1067. 

Reuters  Health  Information  2004.  US.  drug  sales 
$216.4  billion  in  2003  -  IMS  report 
http://www.medscape.com/viewarticle/469471? 
mpid=25157 

American  Heart  Association.  Heart  disease  and  stroke 
statistics  —  2004  update.  Dallas,  American  Heart 
Association,  2003,  Chapter  12:42. 

National  Institute  of  Neurological  Disorders  and 

O 

Stroke.  Questions  and  answers  about  stroke 

http :  /  /  www.  ninds.  nih .  gov  /  health_and_medical  /pub 

s  /  stroke_backgrounder.  htm 

United  Kingdom 

Vlad  I.  Obesity  costs  UK  economy  £2  bn  a  year. 
British  medical  journal,  2003,  327:1308. 

Wise  J.  News:  New  clinical  guidelines  for  stroke 
published.  British  medical  journal,  2000,  320:823. 

Netherlands 

van  Exel  J,  Koopmanschap  MA,  van  Wijngaarden 
JDH,  Scholte  op  Reimer  WJM.  Costs  of  stroke  and 
stroke  services:  determinants  of  patient  costs  and  a 
comparison  of  costs  of  regular  care  and  care 
organised  in  stroke  services.  Cost  effectiveness  and 
resource  allocation,  2003,  1:2 
http:  /  /www.  resource-allocation,  com/content/ 1/1/2 


Polder  JJ,  Meerding  WJ,  Koopmanschap  MA, 
Bonneux  L,  van  der  Maas  PJ.  Cost  of  illness  in  the 
Netherlands  1994.  Rotterdam,  Instituut 
Maatschappelijke  Gezondheidszorg  [Institute  for 
Medical  Technology  Assessment],  Erasmus 
University,  1997 

http :  /  /  www.  ri  vm .  nl  /  kostenvanziekten  /  site_en  / 
index.htm  (in  Dutch) 

Evers  SMAA,  Struijs  JN,  Ament  AJHA,  van 
Genugten  MLL,  Jager  JC,  van  den  Bos  GAM. 
The  disease  impact,  health  care  management,  and  costs  of 
stroke  in  the  Netherlands.  Bilthoven,  National  Institute 
for  Public  Health  and  the  Environment  (RIVM), 
2002  (Report  282701001/2002). 

Singapore 

Venketasubramanian  N,  Yin  A.  Hospital  costs  for 
stroke  care  in  Singapore.  Cerebrovascular  diseases, 
2000,  10:320-326. 

Price  of  weekly  dose  of  medication 

WHO  cardiovascular  Disease  Programme.  Pilot  survey 

O  J 

on  cost  of  cardiovascular  drugs  2003  (unpublished  data). 

The  cost  of  risk  factors 

Liu  K,  Daviglus  ML,  Van  LJ,  Garside  DB,  Greenland 
P,  Manheim  LM,  Dyer  AR,  Stamler  J.  Cardiovascular 
disease  (CVD)  risk  factor  status  earlier  in  adulthood 
and  cumulative  health  care  costs  from  age  65  to  the 
point  of  death.  Circulation,  2004,  108:IV-722. 

Lifetime  costs  of  coronary  heart  disease 

Klever-Deichert  G,  Hinzpeter  B,  Hunsche  E, 
Lauterbach  KW.  Zeitschriftfur  Kardiologie,  1999, 
88:991-1000. 

Expenditure  on  cardiovascular  medications 

Dickson  M,  Jacobzone  S.  Pharmaceutical  use  and 
expenditure  for  cardiovascular  disease  and  stroke:  a 
study  of  1 2  OECD  countries.  Paris,  Organisation  for 
Economic  Co-operation  and  Development,  2003 
(OECD  Health  working  papers, 
DELSA/ELSA/WD/HEA(2003)1),  Table  1. 

Wow:  Aspirin 

Ebrahim  S.  Cost-effectiveness  of  stroke  prevention. 
British  medical  bulletin,  2000,  56:557-570. 


104 


PART  4  ACTION 

18  Research 

Map:  CVD  research  publications;  Regional 
research 

Mendis  S,  Yach  D,  Benpoa  R.  Narvaez  D,  Zhang  X. 

o  o 

Research  gap  in  cardiovascular  disease  in  developing 
countries.  Lancet,  2003,  361:2246-2247. 

Clinical  trials 

Search  by  authors,  24  February  2004. 

Research  funding  by  the  National  Institute  of 
Health  in  the  USA 

United  States  Department  of  Health  and  Human 
Services.  National  Institutes  of  Health.  Estimates  of 
funding  Jbr  various  diseases,  conditions,  research  areas 
http :  /  /  www.  nih .  gov  /  ne  ws  /  fundingresearchareas .  htm 

Wow:  United  Kingdom 

Roth  well  PM.  The  high  cost  of  not  funding  stroke 
research:  a  comparison  with  heart  disease  and  cancer. 
Lancet,  2001,  357(9268):  1612-1616  (review). 

Bennett  R,  Burden  S.  UK  funding  for  stroke 
research.  Lancet,  2001,  358:1275  (correspondence). 

Clipboard 

Mendis  S,  Yach  D,  Bengoa  R,  Narvaez  D,  Zhang  X. 
Research  gap  in  cardiovascular  disease  in  developing 
countries.  Lancet,  2003,  361:2246-2247. 

WHO.  The  World  Health  Report  1 999:  Making  a 
difference.  Geneva,  WHO,  1999,  Annex  Table  3:108 

Text 

Baris  E,  Waverley  Brigden  L,  Prindiville  J,  da  Costa  e 
Silva  VL,  Hatai  C,  Chandiwana  S.  Research  priorities 
for  tobacco  control  in  developing  countries:  a 
regional  approach  to  a  global  consultative  process. 
Tobacco  control,  2000,  9:217-23. 

Tunstall-Pedoe  H,  ed.  MONICA  monograph  and 
multimedia  sourcebook.  Prepared  by  Tunstall-Pedoe  H, 
Kuulasmaa  K,  Tolonen  H,  Davidson  M,  Mendis  S 
with  64  other  contributors  for  The  WHO  MONICA 
Project.  Geneva,  WHO,  2003. 


20  Prevention:  personal  choices  and 
actions 

Personal  choices  in  lifestyles  and  behaviour; 
Personal  actions  for  safeguarding 
cardiovascular  health 

Bulletin  of  the  WHO,  1999. 

Young  people 

Kavey  RW,  Daniels  SR,  Lauer  RM,  Atkins  DL, 
Hayman  LL,  Taubert  K.  American  Heart  Association 
guidelines  for  primary  prevention  of  atherosclerotic 
cardiovascular  disease  beginning  in  childhood. 
Circulation,  2003,  107:1562. 

Eat  fruit  and  cereals 

Pereira  MA,  O'Reilly  E,  Augustsson  K  et  al.  Dietary 
fiber  and  risk  of  coronary  heart  disease.  A  pooled 
analysis  of  cohort  studies.  Archives  of  internal  medicine, 
2004,  164:370-376 

http://archinte.ama-assn.org/cgi/content/abstract/ 
164/4/370 

The  benefits  of  stopping  smoking 

American  Lung  Association.  When  smokers  quit, 
within  twenty  minutes  of  smoking  that  last  cigarette 
the  body  begins  a  series  of  changes 
http: //www.lungusa.org/tobacco/quit_ben. html 

Wow:  USA;  Clipboard:  Burning  calories 

New  "food  pyramid"  to  address  obesity  epidemic. 
Reuters  Health  Information  2004 
http:  /  /www.lifetimefitness.com/health_info/index.c 
fm?strWebAction=health_article&intArticleId=  1 384 

Wow:  Japan 

Schnirring  L.  Can  exercise  gadgets  motivate  patients? 

The  physician  and  sportsmedicine,  news  briefs, 

2001,  29(1) 

http :  /  /  www.  physspor  tsmed .  com  /  issues  /  200 1  / 

01_01 /news. htm 

Wow:  Compared  with  less  active... 

HeartBytes.  Reduce  heart  disease  risk:  encourage  and 

prescribe  exercise  for  your  patients.  Medscape 

cardiology,  2004,  8(1) 

http :  /  /  w  w  w.  medscape .  com  /  viewar  ticle  /  470 115? 

mpid=25341 


105 


Wow:  People  with  low  fitness... 

Carnethon  MR,  Gidding  SS,  Nehgme  R,  Sidney  S, 
Jacobs  DR  Jr,  Liu  K.  Cardiorespiratory  fitness  in 
young  adulthood  and  the  development  of 
cardiovascular  disease  risk  factors.  Journal  of  the 
American  Medical  Association,  2003,  290(23):3092-100. 

Clipboard:  For  people  with  diabetes... 

Standards  of  medical  care  in  diabetes.  Diabetes  care, 
2004,  27(Suppl  1):S1S-3S. 

Bilous  R.  Blood  pressure  control  in  type  2  diabetes  — 
what  does  the  United  Kingdom  Prospective  Diabetes 
Study  (PDS)  tell  us?  Nephrohgj  dialysis  and 
transplantation,  1999,  14:2562    2564. 

Clipboard:  Reducing  salt  intake... 

He  FJ,  MacGregor  GA.  How  far  should  salt  intake  be 
reduced?  Hypertension,  2003,  42(6):  1093-9. 

Text 

O'Keefe  JH  Jr,  Cordain  L.  Cardiovascular  disease 
resulting  from  a  diet  and  lifestyle  at  odds  with  our 
Paleolithic  genome:  how  to  become  a  21st-century 
hunter-gatherer.  Mayo  Clinics  proceedings,  2004, 
79:101-108. 

Carlsson  CM,  Stein  JH.  Cardiovascular  disease  and 
the  aging  woman:  overcoming  barriers  to  lifestyle 

o      o  o  J 

changes.  Current  women's  health  report,  2002, 
2:366-372. 


Wows:  Finland;  Japan;  New  Zealand; 
Mauritius 

World  Health  Report  2002:  reducing  risks, 
promoting  healthy  life.  Cardiovascular  death  and 
disability  can  be  reduced  more  than  50%.  Press 
Release  WHO 783.  17  October  2002:6. 

Clipboard 

Institute  of  Medicine.  Crossing  the  quality  chasm:  a  new 
health  system Jor  the  list  Century.  Washington,  DC, 
National  Academy  Press,  2001 
http://books.nap.edu/books/0309072808/html/ 
1  .html#pagetop 

Text 

Mendis  S.  Role  of  governments  in  improving 
prevention  of  cardiovascular  disease.  Global  Symposium 
on  Cardiovascular  Prevention,  Marbella,  Spain, 
11-13  April  2003. 

Salim  Y.  Two  decades  of  progress  in  preventing 
vascular  disease.  Lancet,  2002,  360 
http://www.thelancet.com/journal/vol360/iss9326 
/full/Han.  360. 9326.  editorial  and  re  view.  2 1674.1 


22  Health  education 

Map:  World  Heart  Day 

World  Heart  Federation.  World  Heart  Day 

http :  /  /  www.  worldhear  tday.  com  /  news  /  news .  asp? 

Page=HeartNews# 


21  Prevention:  population  and 
systems  approaches 

Noncommunicable  disease  prevention  and 
control;  Availability  of  equipment;  Medical 
professionals;  Antihypertensive  drugs 

Alwan  A,  Maclean  D,  Mandil  A.  Assessment  of  national 
capacity  Jor  noncommunicable  disease  prevention  and  control; 
the  report  of  a  global  survey.  Geneva,  WHO,  2001 . 

Use  of  medications  in  stroke  and  coronary 
heart  disease 

Gaps  in  secondary  prevention  of  myocardial 
infarction  and  stroke:  WHO  study  on  Prevention  of 
REcurrences  of  Myocardial  Infarction  and  StrokE 
(WHO-PREMISE)  in  low  and  middle  income 
countries.  WHO-PREMISE  (Phase  I)  Study  Group. 


World  Heart  Day:  themes;  activities; 
Evaluation  of 

World  Heart  Day,  A  World  Heart  Federation 
enterprise  promoting  the  prevention  of  heart  disease 
and  stroke  across  the  world.  Circulation,  2003, 
108:1038-1040. 

Grizeau-Clemens  D.  Evaluation  of  2001  World  Heart 
Day  coverage.  World  Heart  Federation,  2003. 

Giving  up  smoking:  International  Quit  and 
Win 

Vartiainen  ER,  Project  Manager,  International 
Quit&Win,  personal  communication, 
20  January  2004. 


106 


23  Policies  and  legislation 

Map:  Smoke-free  workplaces 

Shafcy  O,  Dolwick  S,  Guindon  GE,  eds.  Tobacco 
control  country  profiles  2003.  Atlanta,  GA,  American 
Cancer  Society,  WHO,  International  Union  Against 
Cancer,  2003. 

Cardiovascular  disease  plans  worldwide; 
Legislation 

Policy  data  from:  WHO.  Capacity  for  NCD 
prevention  and  control  survey  2001 .  Assessment  of 
national  capacity  for  noncommunicable  disease  prevention 
and  control.  The  report  of  a  global  survey.  Geneva, 
WHO,  2001. 

Wow:  2002  USA 

Sargent  RP,  Shcpard  RM,  Glantz  SA.  Reduced 
incidence  of  admissions  for  myocardial  infarction 
associated  with  public  smoking  ban:  before  and  after 
study.  British  medical  journal,  2004,  328:977-980. 


24  Treatment 

Cardiac  rehabilitation;  Patients  reaching 
blood  pressure  and  blood  cholesterol  goals 
during  treatment 

EUROASPIRE  II  Study  Group  (2001).  Lifestyle  and 
risk  factor  management  and  use  of  drug  therapies  in 
coronary  patients  from  1 5  countries.  Principal  results 
from  EUROASPIRE  II  Euro  Heart  Survey 
Programme.  European  heart  journal,  2001, 
22:554-572. 

Simple  secondary  prevention  medication 
treatments 

Yusuf  S.  Two  decades  of  progress  in  preventing 
vascular  disease.  Lancet,  2002,  360:2—3 
http :  /  /  www.  thelancet .  com 

Diabetes  treatment 

Ustun  TB,  Chatterji  S,  Mechbal  A,  Murray  CJL, 
WHS  Collaborating  Groups.  The  World  Health  Surveys 
in  Health  Systems  Performance  Assessment:  debates,  methods 
and  empiricism.  Murray  CJL  and  Evans  DB,  eds, 
Geneva,  WHO,  2003. 


Trends  in  cardiovascular  operations  and 
procedures  in  the  USA 

American  Heart  Association.  Heart  disease  and  stroke 
statistics  -  2004  update.  Dallas,  American  Heart 
Association,  2003. 

Wow:  Proportion  of  people... 

Mensah  GA.  The  global  burden  of  hypertension: 
good  news  and  bad  news.  Cardiology  clinics,  2002, 
20(2):181-185 

Wolf-Maier  K,  Cooper  RS,  Banegas  JR  et  al. 
Hypertension  prevalence  and  blood  pressure  levels  in 
6  European  countries,  Canada,  and  the  United 
States.  Journal  of  the  American  Medical  Association, 
2003,  289(18):2363-2369. 

Wow:  In  the  USA,  only  24%... 
Ford  ES,  Mokdad  AH,  Giles  WH,  Mensah  GA. 
Serum  total  cholesterol  concentrations  and 
awareness,  treatment,  and  control  of 
hypercholesterolemia  among  US  adults:  findings 
from  the  National  Health  and  Nutrition  Examination 
Survey,  1999  to  2000.  Circulation,  2003, 
107(17):2185-2189. 

Text 

Gunn  J,  Grossman  D,  Grech  ED,  Cumberland  D. 
New  developments  in  percutaneous  coronary 
intervention.  British  medical  journal,  2003, 
327(7407):  150-1  5  3. 

Mensah  GA.  Eliminating  health  disparities:  the  time 
for  action  is  now.  Ethnicity  and  disease,  2002, 


PART  5  THE  FUTURE  AND 
THE  PAST 

25  Future 

DALYs;  Deaths 

WHO  (2004).  Unpublished  projections  from  2000 
baseline,  prepared  for  The  World  Health  Report  2002, 
using  projection  methods  developed  by  Murray  CJL, 
Lopez  AD.  The  global  burden  of  disease.  Boston, 
Harvard  School  of  Public  Health,  1996,  Chapter 
7:325-395. 


107 


Risk  factors 

Mackay  J,  Eriksen  M.  The  tobacco  atlas.  Geneva, 
WHO,  2002:90-91. 

Wild  S,  Roglic  G,  Green  A,  Sicree  R,  King  H. 

o  o 

Global  prevalence  of  diabetes.  Estimates  for  the  year 
2000  and  projections  for  2030.  Diabetes  care,  2004, 
27:1047-1053. 

Amos  AF,  McCarty  DJ,  Zimmet  P.  The  rising  global 
burden  of  diabetes  and  its  complications:  estimates 
and  projections  to  the  year  2010.  Diabetes  medicine, 
1997,  14(Suppl5):Sl-S5. 

Collins  R,  Clinical  Trial  Service  Unit,  University  of 
Oxford,  England,  personal  communication, 
6  January  2004. 

Economic  costs 

REUTERS  in  Washington.  United  States:  US  obesity 
weighs  heavy  on  health  costs.  South  China  Morning  Post, 
10  March  2004,  A12  (study  by  Rand  Corporation). 

Action 

Guttmacher  AE,  Collins  FS.  Genomic  medicine: 
a  primer.  New  England  journal  of medicine,  2002, 
347:1512-1550. 

Wolf  CR,  Smith  G,  Smith  RL.  Science,  medicine, 
and  the  future:  pharmacogenetics.  British  medical 
journal,  2000,  320:987-990. 

Mackay  J,  Eriksen  M.  The  tobacco  atlas.  Geneva, 
WHO,  2002:90-91. 

Treatment 

Pearson  I.  Atlas  of  the  future.  New  York,  Macmillan, 
1998:32-33. 

American  Federation  for  Aging  Research.  What  is  the 
future  of  heart  disease  research  likely  to  tell  us? 

http://www.infoa2inp.orp/d-heart-l  1 -future. html 

r  o     o       o 

Roden  DM.  Cardiovascular  pharmacogenomics. 
Circulation,  2003,  108:3071    3074. 

Grossman  D.  Science,  medicine,  and  the  future.  The 
future  of  the  management  of  ischaemic  heart  disease. 
British  medical  journal,  1997,  314:356-359. 


Wald  NI,  Law  MR.  A  strategy  to  reduce 

J  '  c>j 

cardiovascular  disease  by  more  than  80%. 
British  medical  journal,  2003,  326:1419. 

Collins  R,  Clinical  Trial  Service  Unit,  University  of 
Oxford,  England,  personal  communication, 
6  January  2004. 

Text 

Rodpers  A,  Lawes  C.  MacMahon  S.  Reducing  the 

o  o 

global  burden  of  blood  pressure-related  cardiovascular 
disease.  Hypertension,  2000,  18(1  Suppl):S3— 6. 

Lawes  CM,  Bennett  DA,  Feipin  VL,  Rodpers  A. 

to  o 

Blood  pressure  and  stroke:  an  overview  of  published 
reviews.  Stroke,  2004,  35(3):776-85. 

Milestones  in  knowledge  of  heart 
and  vascular  disorders 

Major  sources 

Baddarni  K.  Historic  aspects  of  cardiology 

http:  /  /  www.geocities.com/baddarni/Cardiology- 

History.html 

Weisse  AB.  Heart  to  heart:  the  twentieth  century  battle 
against  cardiac  disease:  an  oral  history.  London,  USA, 
Rutgers  University  Press,  2002. 

Stamler  J.  Lectures  on  preventive  cardiology.  New  York, 
Grune  &  Stratton,  1967  (cited  in  Vance  DE,  van  den 
Bosch  H.  Cholesterol  in  the  year  2000.  Biochemica  et 
biophysica  acta,  2000,  1529:1    8 

Wan  S,  Yim  APC.  The  evolution  of  cardiovascular 
surgery  in  China.  Annals  of  thoracic  surgery,  2003, 
76:2147-55. 

A  timeline  of  milestones  from  The  Framingham 
Heart  Study 
http://www.framingham.com/heart/timeline.htm 

Schooler  C,  Farquhar  JW,  Fortmann  SP,  Flora  JA. 
Synthesis  of  findings  and  issues  from  community 
prevention  trials.  Annals  of  epidemiology,  1997, 
S7:S54-68. 


108 


Useful  contacts 


World  Health  Organization 

http://www.who.int 

Cardiovascular  disease: 

http://www5.who.int/cardiovascular  iliseasfs/ 
Diabetes: 

http://  www.  who.  int  /health_topicsAliabetes_mellitus  /en/ 
Diet: 

http:  //  vvwvv.  who.int/health_topics/dict/en/ 
Nutrition: 

http://  www.  who.  int  /health_topics/ nutrition /en/ 
( )l>r-.it\ : 

http: //www.  who. int/health_topics/obesity/en/ 
Public  Health  Surveillance: 

http:  /  /  www.  w  ho.  int  /  health_topics  /  public_hcalth_sur  veillance  /en  / 
Tobacco  Free  Initiative: 

http://ww-w.who.int/tobacco/en/ 

Centers  for  Disease  Control  and  Prevention,  USA 

http://www.cdc.gov/ 

Cardiovascular  Health  Program: 

http :  /  /  www.  cdc .  gov  /  cvh  / 
Nutrition  and  Physical  Activity  Program: 

http://www.cdc.gov/nccdphp/dnpa/ 
Tobacco  Program: 

to 

http :  /  /  www.  cdc .  gov  /  tobacco  / 
Diabetes  Program: 

http:  // www.cdc.gov/diabetes/ 
Laboratory  Sciences  Program: 

http://www.cdc.gov/nceh/dls/programs.htm 
Office  of  Global  Health: 

http:  // www.cdc.gov/ogh/ 
Behavioral  Risk  Factor  Surveillance  System: 

http:  /  /www.cdc.gov/brfss 
National  Center  for  Health  Statistics: 

http:  /  /www.cdc.gov/nchs 

International  and  Regional  Organisations 

Asian  Society  for  Cardiovascular  Surgery: 

http:  /  /  www.ascvs.org/ 

Association  for  European  Paediatric  Cardiology /Association 
Europeenne  pour  la  Cardiologie  Pediatrique: 

http :  /  /  www.  aepc .  org  /  home .  htm 
Brain  Aneurysm  Foundation: 

http :  /  /  www.  bafound .  org 
Cairdes:  http://www.cairdes.com 
CardioStart  International  Inc: 

http://www.cardiostart.com/ 
Cardiothoracic  Surgery  Network: 

http:  /  /  www.ctsnet.org/ 
Chain  of  Hope:  http://www.chainofhope.org 
Children's  HeartLink: 

http:  /  /www.childrensheartlink.org/ 
Children's  Hearts:  http://www.childrenshearts.org.uk 
Clearinghouse  for  Tobacco  Control  (South  East  Asia): 

http://www.prn2.usm.my/pages/about.asp 
Coeurs  pour  Tous  (Hearts  for  All): 

http :  /  /  www.  cptg.  ch  /  fr  /  start .  htm 
Congenital  Heart  Information  Network: 

http:  /  /www.  tchin.org/ 


Congress  of  Neurological  Surgeons: 
to  c>  to 

http://www.neurosurgeon.org 
Consortium  for  Southeastern  Hypertension  Control  (COSEHC): 

http://www.cosehc.org/ 

East  Meets  West:  http://www.eastmcetswest.org 
Eastern  Mediterranean  Network  on  Heart  Health,  (EMNHH): 

http://emnhh.homestead.com/files/index.htm 
The  Endocrine  Society:  http://www.endo-society.org/ 
European  Association  for  Cardiothoracic  Surgery: 

http://www.eacts.org/ 
European  Heart  Institute: 

http:  /  /  www.european-academy.at 
European  Heart  Network: 

http://www.ehnheart.org/index2.asp 
EMASH  European  Medical  Association  on  Smoking  and  Health: 

http:  /  /emash. globalink.org/ 
ENSH  European  Network  for  Smoke-free  Hospitals: 

http://ensh.free.fr/ 
ENSP  European  Network  for  Smoking  Prevention: 

http://www.ensp.org 
European  Network  of  Young  People  and  Tobacco: 

http://www.ktl.fi/enypat/ 
European  Network  of  Quitlines: 

http://www.quitlines-conference.com/ 
European  Society  for  Noninvasive  Cardiovascular  Dynamics: 

http://www2.mf.uni-lj.si/~esnicvd/ 
European  Society  of  Cardiology: 

http:  /  /www.  escardio.org/ 
European  Society  of  Hypertension: 

http:  /  /  www.eshonline.org/ 
European  Stroke  Initiative: 

http://www.eusi-stroke.com/index.shtml 
European  Union  of  Non-smokers: 

http://www.globalink.org/tobacco/docs/eu-docs/uene.htm 
Framework  Convention  Alliance  (FCA): 

http:  /  /  www.fctc.org/ 
G8  Telematics  Heart  Health  Project: 

http://www.med.mun.ca/g8hearthealth/ 
Gift  of  Life  International  Inc.: 

http://www.giftoflifeinternational.org/ 
Global  Connection  International: 

http :  /  /  w  w  w.  gci  world .  org 
Global  Cardiovascular  Infobase  (in  English  and  Spanish): 

http://www.cvdinfobase.ca/ 

Global  Healing:  http://www.globalhealing.org 
to          r  b  to      to 

Global  Health  Information  Network: 

http:  /  /  www.healthnet.org/ 
Global  Partnerships  for  Tobacco  Control: 

http:  /  /  www.essentialaction.org/tobacco/ 
Globalink,  UICC  International  Union  against  Cancer: 

http:  // www.globalink.org/ 
Healing  the  Children: 

http://www.healingchildren.org 
Heart  Care  International: 

http:  /  /www.  heartcareintl.org 
HeartGift  Foundation: 

http://www.heartgift.org/index.html 
The  Heart  of  a  Child  Foundation  -  Little  Hearts  on  the  Mend: 

http :  /  /  www.  littleheartsonthemend .  org 
Heart-to-Heart  International: 

http :  /  /  www.  hearttoheart .  org/ 


109 


Heart-to-Heart  International  Children's  Medical  Alliance: 

http://www.heart-2-heart.org/ 
Initiative  for  Cardiovascular  Health  Research  in  Developing  Countries: 

http://www.globalforumhealth.org/pages/index.asp? 
ThePage=page1_OOOS00040001_l.htm&Nav=OOOS00040001 
Inter  American  Heart  Foundation: 

http :  /  /  www.  interamericanhear  t .  org 
Inter  American  Society  of  Cardiology  (in  Spanish  and  English): 

http ://  www.  soinca .  org 
Inter-American  Society  of  Hypertension: 

http://org.umc.edu/iash/homepage.htm: 

http://www.musc.edu/iash/generale.htm 
International  Academy  of  Cardiology: 

http://www.cardiologyonline.com/ 
International  Agency  on  Tobacco  and  Health  (IATH): 

Email:  admin@iath.org 

^~s  o 

International  Atherosclerosis  Society: 

http :  /  /  w  ww.athero.  org/ 
International  Children's  Heart  Foundation: 

http://www.ichf.org/ 
International  Children's  Heart  Fund: 

http://www.ichfund.org/ 
International  Diabetes  Federation: 

http:  /  /  www.idf.org/ 
International  Diabetes  Institute,  Australia: 

http ://  www.  diabetes .  com .  au  /  home .  htm 
International  Federation  of  Sports  Medicine: 

http://www.fims.org/ 
International  Hospital  for  Children  (IHC): 

http:  /  /  www.healachild.org 
International  Network  of  Women  against  Tobacco  (IN WAT): 

http://www.inwat.org/ 
International  Network  towards  Smoke-Free  Hospitals  (INTSH): 

http://intsh.plobalink.org/ 
r  o  o 

International  Non  Governmental  Coalition  against  Tobacco  (INGCAT): 

http://www.ingcat.org/ 
r  o  o 

International  Obesity  Task  Force: 

http://www.iotf.org/ 
International  Pediatric  Hypertension  Association: 

http://www.pediatrichypertension.org/ 
International  Society  for  Adult  Congenital  Cardiac  Disease: 

http://www.isaccd.org/ 
International  Society  for  Aging  and  Physical  Activity: 

http://www.isapa.org/ 
International  Society  for  Cardiovascular  Surgery: 

http://www.vascsurg.org/doc/ 1  S76.html##.htm 
International  Society  for  Heart  Research: 

http :  /  /  www.  ishrworld .  org/ 
International  Society  for  Heart  &  Lung  Transplantation: 

http://www.ishlt.org/ 
International  Society  for  Minimally  Invasive  Cardiac  Surgery: 

http://www.ismics.org/ 

International  Society  for  the  Prevention  of  Tobacco  Induced  Diseases 
(PTID):  http://www.ptid.org 
International  Society  of  Cardiovascular  Ultrasound: 

http://www.iscu.org/ 
International  Society  of  Hypertension: 

http://www.hypertension2004.com.br/ 
International  Society  of  Nephrology: 

http:  /  /  www.isn-online.org/ 
International  Society  on  Hypertension  in  Blacks  (ISHIB): 

http:  //www.ishib.org/main/ishib_opcn.  htm 
International  Stroke  Society: 

http://www.internationalstroke.org/index.php 
International  Task  Force  for  the  Prevention  of  Coronary  Heart  Disease: 

http://www.chd-taskforce.de/ 


International  Tobacco  Evidence  Network  (ITEN): 

http :  /  /  w  w  w.  tobaccoevidence .  net  / 
The  Internet  Stroke  Center: 

http://www.strokecenter.org/pat/organi7.ations.htm 
Legacy  Foundation,  tobacco  document  site: 

http://legacy.library.ucsf.edu/cgi/b/bib/bib-idx?g=tob 
Mediterranean  Stroke  Society: 

http://www.hsanmartino.liguria.it/cictus/med.htm 
OTAF  L'Observatoire  du  Tabac  en  Afrique  Francophone: 

http:  /  /otaf.globalink.org/ 

Physicians  lor  Peace:  http://www.physiciansforpeace.org 
ProCOR:  Conference  on  Cardiovascular  Health: 

http://www.procor.org/ 
Project  Hope:  http://www.projecthope.org 
Project  Kids  Worldwide: 

http:  /  /www.projectkidsworldwide.org 
Project  Open  Hearts:  http://www.poh.org 
Repace's  site,  especially  on  passive  smoking  (Jim  Repace): 

http://www.repace.com/ 
Save  A  Child's  Heart  Foundation: 

http://www.saveachildsheart.com 
Society  for  Research  on  Nicotine  and  Tobacco  (SRNT): 

http:  /  /  www.srnt.org/ 
Smokescreen  Action  Network: 

http://www.smokescreen.org 
Southeast  Asian  Tobacco  Control  Alliance: 

http:  /  /www.  tobaccofreeasia.net/ 
Stroke  Awareness  for  Everyone: 

http://www.strokesafe.org/ 
Stroke  Clubs  International: 

Email:  strokeclub@aol.com 
Stroke  Net: 

http :  /  /  www.  strokenet .  info /resources/  stroke  /  internationalsites.  htm 
Surgeons  of  Hope  Foundation: 

http :  /  /  w  w  w.  surgeonsofhope .  org 
Tobacco,  org :  http :  /  /  www.  tobacco,  org 
Tobacco  Control  journal: 

http :  /  /  w  w  w.  tobaccocontrol .  com 

Tobacco  Control  Resource  Center /Tobacco  Products  Liability  Project 
(TCRC/TPLP):  http://tobacco.neu.edu/ 
TCRC  Tobacco  Control  Resource  Centre,  BMA,  UK: 

http:  /  /www.tobacco-control.org/ 
Tobacco  Control  Supersite: 

http :  /  /  www.  health  .usyd.edu.au/  tobacco  / 
Tobacco  Documents  Online  (TDO,  Smokescreen: 

http:  /  /www.  tobaccodocuments.org 
Tobaccopedia: 

http:  /  /  TobaccoPedia.org 

Treatobacco  Database  &  Educational  Resource  for  Treatment  of 
Tobacco  Dependence: 

http://www.treatobacco.net/ 
World  Federation  of  Neurology: 

http://www.wfneurology.org/ 
World  Heart  Federation: 

http://www.worldheart.org/ 
World  Heart  Foundation: 

http://www.world-heart.org/ 
World  Hypertension  League: 

http  ://www.mco.edu/  org  /  whl  / 
World  Kidney  Foundation: 

http :  /  /  www.  worldkidneyfund  .org/ 
World  Medical  Association: 

http://www.wma.net/ 


110 


Index 


activity  see  physical  activity  and 

inactivity 

ACE  inhibitors  40,  71,92 
age,  advancing  19,  25,  42 
alcohol  use  19,  24-25 
ancurysm  see  aortic  aneurysm  and 

dissection 

angina  pectoris  32,  77,  78 
angioplasty  71,  79,  92 
anticoagulant  92 
antihypertensive  drugs  65 
aortic  aneurysm  and  dissection  19,  32 
arrhvthmia  71 ,  92 
arteriosclerosis  76,  92 
artificial  body  parts  71 ,  75,  80 
arterial  disease,  peripheral  19,  32,  76 
aspirin  55,  65,  71,  78,79,  80,  81 
atherosclerosis  26,  31,  32,  42,  77,  92 
atrial  fibrillation  19,  20,  50,  52,  78, 

80,  92 

beta-blockers  71 
blood  clotting 

O 

disorders  19,  25,  32;  see  also 

stroke 

treatment  of  80,  81 
blood  pressure  28-29,  32,  48, 

62-63,  66,  70,  77,  78,  80,  92 

high  19,  24-25,  26,  28-29,  32, 

34,  40,  42,  50,  52,  63,  64,  70, 

79,  93 

see  also  hypertension  and 

hypertensive  heart  disease 
blood  sugar  levels  62 
body  mass  index  (BMI)  36-37,  92 
brain  tumours,  vascular  19 
bypass  see  coronary  artery  bypass 

surgery 

cardiac 

defibrillation71,78,  79 

pacemakers  71,  78,  79 

rehabilitation  70 

see  also  coronary  and  heart 
cardiovascular  disease  (CVD)  92 

deaths  from  18,  74 

disability-adjusted  life  years 

(DALYs)  74 

investigations  for  75 

economic  costs  of  5  5 

medication  for  65,  71,  75,  77 


prevention  of  62— 63,  64—65,  66- 

67,  68,  80,  81 

research  into  58-59,  75 

risk  factors  24 — 43 

surgery  70-71,  75,  78,  79,  80,  81 

types  of  18-19 
carotid 

endarterectomy  71 

stenosis  52,  92 
cars  see  motor  vehicles 
Centers  for  Disease  Control  and 

Prevention  (USA)  60 
cerebrovascular  disease  see  stroke 
childbirth  19 
children  and  youth  20—21,  25, 

26-27,  38,  51,  62,  66 
cholesterol  19,  24-25,  30-31,  40, 

42,48,  62,  65,  70-71,  77,  79, 

80,  81,  92 

HDL  (high-density  lipoprotein) 

25,  30,  32,42,  80,  93 

LDL  (low-density  lipoprotein) 

25,  30,  32,  80,  93 

plaques  32,  77,  92 
cigarettes  see  tobacco  use 
clotting  see  blood  clotting 
contraceptive,  oral  19,  25,  42,  50 
coronary 

artery  bypass  surgery  71 ,  92 

artery  disease  79 

artery  spasm  32 

stent71,  80,  93 

see  also  cardiac  and  heart 
coronary  heart  disease  19,  32, 

34-35,  40,  52,  92 

burden  46—47 

deaths  from  1819,  35,  46-47, 

48-49,  74 

disability-adjusted  life  years 

(DALYs)  46-4-7,  74 

economic  costs  of  55 

medication  for  65,  71,  81 

prevention  of  48 

research  into  58—59 

risk  factors  19,  79 
costs  see  economic  costs 

deaths  from 

cardiovascular  disease  18,  74 
coronary  heart  disease  18—19,  35, 
48-49,  74 


diabetes  mellitus  48 

hypertensive  heart  disease  18,  48 

inflammatory  heart  disease  1 8 

physical  inactivity  35 

rheumatic  heart  disease 

18, 20-21 

stroke  18-19,  48,  50-51,  52-53, 

74 

tobacco  use  74 
deep  venous  thrombosis  1 9 
diabetes  mellitus  19,  25,  34,  38-39, 

40-41,42,48,  52,  63,  64,  75, 

80,  81,92 

deaths  from  48 

economic  costs  of  54 

predicted  number  of  people  with 

75 

research  into  58-59 

treatment  of  7 1 

type  1  diabetes  38 

type  2  diabetes  26,  36,  38,  54 
diet  19,  24-25,  26,  28,  36,  42,  48, 

52,  62-63,  64,  66,  77,  80; 

see  also  food 
digitalis  77 
disability-adjusted  life  years  (DALYs) 

46-4-7,  50-51,  74,  92 

economic  costs  54—55,  75,  92,  93 
education 

health  66  67 

level  of  19,  28,  40,41 
electrocardiogram  (ECG)  78,  79 
embolism  see  pulmonary  embolism 
ethnicity  and  race  25,  42 

food  30,  36,  62 
cereals  63 
fast  68 

fruit  and  vegetables  24,  28,  36, 
62-63,  64 
labelling  of  65,  68 
legislation  on  69 

O 

processed  28 
see  also  diet 
future  74-75 

gender  differences  25,  27,  28—29, 
32-33,42-43,81; 
see  also  women 


111 


genetic 

disposition  19,  25,48,  81 

science  75 

therapy  8 1 

see  also  heredity 

HDL-cholesterol  see  cholesterol, 

HDL 
health  see  also  education,  health  and 

mental  health  and  public  health 

and  tobacco  use,  health  warnings 
health  care 

access  to  40 

economic  costs  of  54 — 55 
heart  1 8 

attack  30,  32,  93 

catheterization  71,  78 

congenital  disease  1 9 

failure,  congestive  92 

inflammatory  disease  18—19,  81 

muscle  18-19,  77 

transplantation  71,  75,  79,  81 

tumours  19 

valves  19,  20,  71,  76,  79 

see  also  cardiac  and  coronary  and 

hypertensive  heart  disease 
heredity  25,  42  see  also  genetic 
homocysteine  levels  in  blood 

19,  25,93 
hormone  replacement  therapy 

19,  25,42-43 
hypertension  28 

see  also  blood  pressure,  high 
hypertensive  heart  disease 

deaths  from  18,  48 

see  also  blood  pressure,  high 

inactivity  see  physical  activity  and 

inactivity 
International  Conferences  on 

Preventive  Cardiology  60 
International  Heart  Health 

Conferences  and  Declarations  6 1 , 

64,  66-67, 81 

labelling  see  food 

LDL-cholesterol  see  cholesterol,  LDL 

left  ventricular  hypertrophy  25 

legislation  68-69 

Iipids25,  26,  30-31,  34,  52,93 

lowering  medication  40,  71 

see  also  cholesterol 


medical  professionals  42,  62,  65 
medication  42,  54-55,  62,  65,  71 ,  75, 

77,81 

mental  health  19,  25 
MET  (metabolic  equivalent)  35,  93 
motor  vehicles  34—35 
myocardial  infarction  see  heart  attack 

nutrition  see  food  and  diet 

obesity  19,  24-25,  26,  34,  36-37, 
41,42,  62,  65,  66,  79,  80,  93 
economic  costs  of  54—55,  75 

open  heart  surgery  71,79 

operations  71 

organizations  60—61 

physical  activity  and  inactivity 
19,  24-25,  26-27,  28,  34-35, 
40,  42-4-3,  48,  54,  62-63,  66, 
78,79,80,81,93 

policies  68—69 

poverty  19,  20 

prevention  see  cardiovascular  disease, 
prevention  of 

public  health 

initiatives  64—65 
policy  68-69 

pulmonary  embolism  1 9 

Quit  and  Win  67 

race  see  ethnicity  and  race 
rehabilitation  70 
research  58^59,  75,  76-81 
rheumatic  fever  20,  78,  93 
rheumatic  heart  disease  19,  20— 21 ,  93 

deaths  from  18,  20-21 
risk  factors  19,  24-43,  55,  62-63, 

66-67,  79,  80 

salt  intake  28,  52,  63,  65 
schools 

health  education  in  66 
smoking  see  tobacco  use 
socioeconomic  status  25,  34,  40—41, 

52 

sphygmomanometer  78 
statins  65,  81 
stent  see  coronary  stent 
streptococcal  infection  19,  20 
stress  25,  34,  40,  42,  62,  77 
stroke  19,  20,  30,  32,  34,  50-53, 

76,  78,  80,  93 

burden  50-5 1 


carotid  stenosis  52 
deaths  from  18-19,48,  50-51, 
52-53,  74 

disability-adjusted  life  years 
(DALYs)  505 1 
economic  costs  of  54—55 
medication  for  65,  71 ,  80 
research  into  58-59 
risk  factors  19,  63,  79,  80 
young  people  5 1 

surgery  see  coronary  artery  bypass 
surgery  and  open  heart  surgery 
and  cardiovascular  disease  surgery 

o       J 

technology  70-71 ,  75,  77-81 
thrombosis  see  deep  venous  thrombosis 
tobacco  use  19,  24-25,  26-27, 
32-33,  40-41,  42-4-3,  48,  50, 
52,  62,  74,  79,  80,  81 
deaths  from  74 
economic  costs  of  54—55 
health  warnings  about  68 
knowledge  of  risks  32—33 
legislation  on  69 
passive  smoking  32,  62 
prevalence  of  27,  33,  75 
quitting  smoking  33,  62   63,  67 
smoke-free  areas  68—69,  81 
transplant  see  heart  transplantation 
treatment  64-65,  70-71,  75,  80 
triglycerides  30,  42,  80,  93 

United  Nations  Conventions  and 
Goals  75 

vascular  disease,  peripheral  92 

women  25,  28-29,  30,  32-33,  42-43 
World  Congresses  of  Cardiology  60 
World  Health  Assembly  68,  81 
World  Health  Organization  60-6 1 , 
79,  81 

Framework  Convention  on 
Tobacco  Control  68-69,  81 
Global  School  Health  Initiative  66 
Global  School-based  Student 
Health  Survey  66 
Global  Strategy  on  Diet,  Physical 
Activity  and  Health  8 1 
World  Heart  Days  66-67,  81 
World  Heart  Federation  60,  66-67, 

79 
World  Stroke  Congresses  61 

youth  see  children  and  youth 


112 


"Heart  disease  and  stroke  rob  too  many  people  of 

precious  years  of  quality  life.  This  one-of-a-kind 

atlas  serves  as  a  key  resource  for  those  on  the 

frontlines  of  health.  "  Dr  Julie  Gerberding,  Director, 

Centers  for  Disease  Control  and  Prevention,  Atlanta,  Georgia,  USA 

"We  applaud  the  authors  for  producing  such  a 
comprehensive  document  in  such  a  user-friendly 

format."   World  Heart  Federation 


Heart  disease  can  no  longer  be  seen  as  the  problem  of  overworked, 
overweight  middle-aged  men;  in  today's  world,  we  are  all  -  women 
and  children  too  -  at  risk.  One  in  three  deaths  worldwide 
-17  million  deaths  each  year  -  is  due  to  cardiovascular  disease. 


These  full-colour  maps  and  graphics  illustrate 
the  wide  range  of  issues  relating  to  this  global 
epidemic,  including: 

Risk  factors: 

high  blood  pressure,  tobacco,  inactivity, 
obesity,  lipids,  diabetes 

Women,  childhood  and  youth 


The  global  burden  of 
cardiovascular  disease 

Research 
Prevention 

Policies  and  legislation 
Treatment 
The  future 


Trends  in  cholesterol  levels  in  Beijing, 

Mean  total  cholesterol  in  people  aged  25-64  year 

1984- 1999 

mmol/l 


Men 

4.15 

* 
1984 


Front  cover  photograph: 

Amy,  Hong  Kong  ®  Guy  Nowell 

Back  cover  photographs: 
Cardiology  operation,  Mauritius  e 
WHO/Harry  Anenden; 
Man  selling  vegetables,  India  ® 
WHO/ Pierre  Virot;  Man  on  bencl 
®  iStock/Tomaz  Levstek;  Woman 
and  girl  buying  sweets,  India  * 
WHO/Pierre  Virot;  Bowl  of  rice  ® 
Hemera  Photo-Objects 

Cover  design:  Corinne  Pearlman 


o 

m 


a  myriad  edition 

ISBN  92  4  156276  8 


World  Health  Organization 

www.who.int 


9  789241    562768